Recurrent miscarriage causes. Abortions in the past

Today, miscarriage is considered one of the most important issues obstetrics, given the variety of causes and the ever-increasing percentage of perinatal losses. According to statistics, the number of recorded cases of miscarriage is 10-25%, with 20% of them related to habitual miscarriage, and 4-10% are preterm births (relative to the total number of births).

What does this term mean

• The duration of pregnancy is 280 days or 40 weeks (10 obstetric months).
• Births at term are considered those births that occurred within 38 - 41 weeks.
• Miscarriage is called its spontaneous interruption, which occurred in the period from fertilization (conception) to 37 weeks.

Recurrent miscarriage refers to cases of spontaneous abortion that occurred twice or more in a row (including miscarriage and antenatal fetal death). The frequency of habitual miscarriage in relation to the total number of all pregnancies reaches 1%.

The risks of miscarriage are directly proportional to the number of previous miscarriages in history. Thus, it has been proven that the risk of terminating a new pregnancy after the first spontaneous abortion is 13 - 17%, after two miscarriages / preterm birth it reaches 36 - 38%, and after three spontaneous interruptions it is 40 - 45%.

Therefore, every couple who has had 2 miscarriages should be carefully examined and treated at the stage of pregnancy planning.

In addition, it has been proven that the age of a woman is directly related to the risk of spontaneous abortions in the early stages. If women in age category from 20 to 29 years the possibility of spontaneous abortion is 10%, then at 45 years and after it reaches 50%. The risk of abortion with increasing maternal age is associated with the "aging" of the eggs and an increase in the number of chromosomal abnormalities in the embryo.

Classification

The classification of miscarriage includes several points:

Depending on the period of occurrence

• spontaneous (spontaneous or sporadic) abortion is divided into early (up to 12 weeks of gestation) and late from 12 to 22 weeks. Spontaneous miscarriages include all cases of abortion that occurred before 22 weeks or with a fetal body weight of less than 500 grams, regardless of the presence / absence of signs of his life .;
• preterm births, which are distinguished by timing (according to WHO): from 22 to 27 weeks, ultra-early preterm births, births that occurred from 28 to 33 weeks are called early preterm births and from 34 to 37 weeks are called preterm births.

Depending on the stage, abortions and premature births are divided into:

• spontaneous abortion: threatened abortion, abortion in progress, incomplete abortion (with remnants of the ovum in the uterus) and complete abortion;
• preterm labor, in turn, is classified as: threatening, beginning (at these stages, labor activity can still be slowed down) and begun.

Separately, an infected (septic) abortion, which may be criminal, and a failed abortion (a missed or non-developing pregnancy) are distinguished.

Causes of miscarriage

The list of causes of miscarriage is very numerous. It can be divided into two groups. The first group includes social and biological factors, which include:

To the second group include medical reasons that are due either to the condition of the embryo/fetus or the health of the mother/father.

Genetic causes of miscarriage

Genetic miscarriage is noted in 3-6% of cases of pregnancy losses, and for this reason, about half of pregnancies are interrupted only in the first trimester, which is associated with natural selection. When examining spouses (karyotype study), about 7% of failed parents show balanced chromosomal rearrangements that do not affect the health of the husband or wife in any way, but during meiosis, difficulties arise in the processes of pairing and separation of chromosomes. As a result, unbalanced chromosomal rearrangements are formed in the embryo, and it becomes either unviable and the pregnancy is interrupted, or is a carrier of a severe chromosomal abnormality. The possibility of having a child with severe chromosomal pathology in parents who have balanced chromosomal rearrangements is 1 - 15%.

But in many cases, the genetic factors of miscarriage (95) are represented by a change in the set of chromosomes, for example, monosomy, when one chromosome is lost, or trisomy, in which there is an extra chromosome, which is the result of errors during meiosis due to the influence of harmful factors (drugs, radiation, chemical hazards). and others). Polyploidy also refers to genetic factors, when the chromosome composition increases by 23 chromosomes or a complete haploid set.

Diagnostics

Diagnosis of genetic factors of recurrent miscarriage begins with the collection of anamnesis from both parents and their close relatives: are there any hereditary diseases in the family, are there any relatives with congenital anomalies, were there children with a delay mental development spouses, whether the spouses or their relatives had infertility or miscarriage of unknown origin, as well as cases of idiopathic (unspecified) perinatal mortality.

Of the special examination methods, a mandatory study of the karyotype of the spouses is shown (especially at the birth of a child with congenital malformations and in the presence of habitual miscarriage in the early stages). A cytogenetic study of abortus (karyotype determination) is also shown in cases of stillbirth, miscarriage and infant mortality.

If changes are found in the karyotype of one of the parents, a consultation with a geneticist is indicated, who will assess the degree of risk of having a sick child or, if necessary, recommend the use of a donor egg or spermatozoa.

Management of pregnancy

In the event of pregnancy, a mandatory prenatal diagnosis (chorionic biopsy, cordocentesis or amniocentesis) is performed in order to detect gross chromosomal pathology of the embryo/fetus and possible interruption pregnancy.

Anatomical causes of miscarriage

The list of anatomical causes of miscarriage includes:

• congenital malformations (formation) of the uterus, which include its doubling, bicornuate and saddle uterus, uterus with one horn, intrauterine septum, complete or partial;
• anatomical defects that appeared during life (intrauterine synechia, submucosal myoma, endometrial polyp)
• isthmic-cervical insufficiency (insolvency of the cervix).

habitual miscarriage, due to anatomical causes, is 10 - 16%, and the share of congenital malformations is 37% for a bicornuate uterus, 15% for a saddle uterus, 22% for a septum in the uterus, 11% for a double uterus and 4.4% for a uterus with one horn .

Miscarriage with anatomical uterine anomalies is due either to unsuccessful implantation of a fertilized egg (directly on the septum or near the myomatous node) or insufficient blood supply to the uterine mucosa, hormonal disorders, or chronic endometritis. Isthmic-cervical insufficiency stands out as a separate line.

Diagnostics

The anamnesis contains indications of late miscarriages and premature birth, as well as pathology of the urinary tract, which often accompanies malformations of the uterus and features of the formation menstrual cycle(there was a hematometra, for example, with a rudimentary horn of the uterus).

Additional examination methods

From additional methods in case of miscarriage, the cause of which is anatomical changes, apply:

• metrosalpingography, which allows you to determine the shape of the uterine cavity, identify existing submucosal myomatous nodes and endometrial polyps, as well as determine the presence of synechia (adhesions), intrauterine septum and tubal patency (performed in the 2nd phase of the cycle);
• allows you to see with the eye the uterine cavity, the nature of the intrauterine anomaly, and, if necessary, dissect the synechia, remove the submucosal node or endometrial polyps;
• Ultrasound of the uterus allows you to diagnose submucosal fibroids and intrauterine synechia in the first phase, and in the second it reveals a septum in the uterus and a bicornuate uterus;
• in some difficult situations, magnetic resonance imaging of the pelvic organs is used, which makes it possible to detect abnormalities in the development of the uterus with concomitant atypical localization of organs in the small pelvis (especially in the case of a rudimentary uterine horn).

Treatment

Treatment of recurrent miscarriage, due to the anatomical pathology of the uterus, consists in the surgical excision of the uterine septum, intrauterine synechia and submucosal myoma nodes (preferably during hysteroscopy). The effectiveness of surgical treatment of this type of miscarriage reaches 70 - 80%. But in the case of women with a normal course of pregnancy and childbirth in the past, and then with recurrent miscarriages and with uterine malformations, surgical treatment has no effect, which may be due to other causes of miscarriage.

After surgical treatment, in order to improve the growth of the uterine mucosa, combined oral contraceptives are indicated for 3 months. Physiotherapy is also recommended (,).

Management of pregnancy

Pregnancy against the background of a bicornuate uterus or with its doubling proceeds with the threat of miscarriage in different dates and with the development placental insufficiency and fetal growth retardation. Therefore, from an early date, if bleeding occurs, bed rest, hemostatics (dicinone, tranexam), antispasmodics (magne-B6) and sedatives (motherwort, valerian) are recommended. It also shows the use of gestagens (utrozhestan, duphaston) up to 16 weeks.

Isthmic-cervical insufficiency

ICI is one of the most common factors of late miscarriage, mainly in the 2nd trimester. Isthmic-cervical insufficiency is regarded as a failure of the cervix, when it cannot be in a closed position, and as it progresses, it shortens and opens, and the cervical canal expands, which leads to prolapse of the fetal bladder, its opening and discharge of water and ends with a late miscarriage or premature birth . Distinguish ICI functional (hormonal failures) and organic (post-traumatic) character. This reason habitual miscarriage occurs in 13 - 20% of cases.

Diagnostics

It is not possible to estimate the risk of developing functional CI before pregnancy. But in the presence of post-traumatic CCI, metrosalpingography is indicated at the end of the 2nd phase of the cycle. If an extension is diagnosed internal os more than 6 - 8 mm, the sign is regarded as unfavorable, and the woman with the onset of pregnancy is included in the high risk group for miscarriage.

During pregnancy, it is shown weekly (starting from 12 weeks) to assess the condition of the cervix (its examination in the mirrors, ultrasound scanning of the cervix and determination of its length, as well as the condition of the internal os using transvaginal ultrasound).

Treatment

Treatment of miscarriage before pregnancy consists in surgical intervention on the cervix (with post-traumatic insufficiency), which consists in the plastic of the cervix.

When pregnancy occurs, a surgical correction of the cervix (suturing) is performed in terms from 13 to 27 weeks. Indications for surgical treatment are softening and shortening of the neck, expansion of the external os and opening of the internal os. In the postoperative period, vaginal smears are monitored and, if necessary, the vaginal microflora is corrected. In case of increased uterine tone, tocolytics (ginipral, partusisten) are prescribed. Subsequent pregnancy management includes examination of the sutures on the neck every 2 weeks. Stitches are removed at 37 weeks or if emergency(leakage or outpouring of water, appearance blood secretions from the uterus, cutting the sutures and in the case of the onset of regular contractions, regardless of the gestational age).

Endocrine causes of miscarriage

Miscarriage due to hormonal reasons, occurs in 8 - 20%. In the forefront are pathologies such as luteal phase deficiency, hyperandrogenism, hyperprolactinemia, thyroid dysfunction and diabetes mellitus. Among the habitual miscarriage of endocrine genesis, luteal phase insufficiency occurs in 20-60% and is caused by a number of factors:

• failure of the synthesis of FSH and LH in the 1st phase of the cycle;
• early or late LH surge;
• hypoestrogenism, as a reflection of the inadequate maturation of the follicles, which is due to hyperprolactinemia, an excess of androgens and.

Diagnostics

When studying the anamnesis, attention is paid to the late formation of menstrual function and the irregularity of the cycle, a sharp increase in body weight, existing infertility or habitual spontaneous abortions in the early stages. On examination, the physique, height and weight, hirsutism, the severity of secondary sexual characteristics, the presence of "stretch marks" on the skin, and the mammary glands are assessed to exclude/confirm galactorrhea. The graph of basal temperature for 3 cycles is also evaluated.

Additional examination methods

• Determining the level of hormones

In phase 1, the content of FSH and LH is examined, thyroid-stimulating hormone and testosterone, as well as 17-OP and DHES. In phase 2, the level of progesterone is determined.

Ultrasound monitoring is carried out. In phase 1, endometrial pathology and the presence / absence of polycystic ovaries are diagnosed, and in phase 2, the thickness of the endometrium is measured (normally 10-11 mm, which coincides with the level of progesterone).

• Biopsy of the endometrium

To confirm the insufficiency of the luteal phase, endometrial aspiration is performed on the eve of menstruation.

Treatment

In case of confirmation of luteal phase deficiency, it is necessary to identify and eliminate its cause. With NLF against the background of hyperprolactinemia, MRI of the brain or X-ray of the skull is indicated (to evaluate the Turkish saddle - to exclude pituitary adenoma, which requires surgical intervention). If no pathology of the pituitary gland is found, a diagnosis of functional hyperprolactinemia is made and therapy with bromocriptine is prescribed. After the onset of pregnancy, the drug is canceled.

In the case of a diagnosis of hypothyroidism, treatment with levothyroxine sodium is prescribed, which is continued after the onset of pregnancy.

Direct NLF therapy is carried out in one of the following ways:

• ovulation stimulation with clomiphene from the 5th to the 9th day of the cycle (no more than 3 cycles in a row);
• replacement treatment with progesterone preparations (utrogestan, dufaston), which supports the full secretory transformation of the endometrium in case of preserved ovulation (after pregnancy, progesterone therapy is continued).

After the use of any method of treatment for NLF and the onset of pregnancy, treatment with progesterone preparations is continued for up to 16 weeks.

Adrenal hyperandrogenism or adrenogenital syndrome

This disease is hereditary and is caused by a violation of the production of hormones of the adrenal cortex.

Diagnostics

In the anamnesis there are indications of late menarche and an extended cycle up to oligomenorrhea, spontaneous abortions in the early stages, infertility is possible. On examination, acne, hirsutism, a male-type physique, and an enlarged clitoris are revealed. According to the graphs of basal temperature, anovulatory cycles are determined, alternating with ovulatory cycles against the background of NLF. Hormonal status: high content of 17-OP and DGES. Ultrasound data: the ovaries are not changed.

Treatment

Therapy consists in the appointment of glucocorticoids (dexamethasone), which suppress the excess production of androgens.

Management of pregnancy

Treatment with dexamethasone is continued after pregnancy until childbirth.

Ovarian hyperandrogenism

Another name for the disease is polycystic ovaries. In the anamnesis there are indications of a late menarche and a violation of the cycle by the type of oligomenorrhea, rare and ending with early miscarriages of pregnancy, long periods of infertility. On examination, there is increased hair growth, acne and striae, and overweight. According to the graphs of basal temperature, periods of anovulation alternate with ovulatory cycles against the background of NLF. Hormonal level: high performance testosterone, possibly increasing FSH and LH, and ultrasonography reveals polycystic ovaries.

Treatment

Therapy for hyperandrogenism of ovarian origin consists in the normalization of weight (diet, physical activity), stimulation of ovulation with clomiphene and support of the 2nd phase of the cycle with gestagenic preparations. Conducted according to indications surgical intervention(wedge-shaped excision of the ovaries or laser treatment).

Management of pregnancy

When pregnancy occurs, progesterone preparations are prescribed up to 16 weeks and dexamethasone up to 12-14 weeks. The state of the cervix is ​​checked and, with the development of ICI, it is sutured.

Infectious causes of miscarriage

The question of the significance of the infectious factor as the cause of repeated pregnancy losses is still open. In the case of primary infection, pregnancy is terminated early, due to damage to the embryo that is incompatible with life. However, in most patients with recurrent miscarriage and existing chronic endometritis, several types of pathogenic microbes and viruses predominate in the endometrium. The histological picture of the endometrium in women with recurrent miscarriage in 45 - 70% of cases indicates the presence of chronic endometritis, and in 60 - 87% there is an activation of opportunistic flora, which provokes the activity of immunopathological processes.

Diagnostics

In case of miscarriage of an infectious genesis in the anamnesis, there are indications of late miscarriages and premature births (for example, up to 80% of cases of premature discharge of water are the result of inflammation of the membranes). Additional examination (at the stage of pregnancy planning) includes:

• smears from the vagina and cervical canal;
• tank. sowing the contents of the cervical canal and quantifying the degree of contamination with pathogenic and opportunistic bacteria;
• detection of genital infections by PCR (gonorrhea, chlamydia, trichomoniasis, herpes virus and cytomegalovirus);
• determination of immune status;
• determination of immunoglobulins in cytomegalovirus and herpes simplex virus in the blood;
• study of interferon status;
• determination of the level of anti-inflammatory cytokines in the blood;
• biopsy of the endometrium (curettage of the uterine cavity) in the 1st phase of the cycle, followed by a histological examination.

Treatment

Treatment of miscarriage of an infectious nature consists in the appointment of active immunotherapy (plasmapheresis and gonovaccine), antibiotics after provocation, and antifungal and antiviral drugs. Treatment is selected individually.

Management of pregnancy

When pregnancy occurs, the condition is monitored vaginal microflora, as well as studies for the presence of pathogenic bacteria and viruses. In the first trimester, immunoglobulin therapy is recommended (the introduction of human immunoglobulin three times a day) and placental insufficiency is prevented. In the 2nd and 3rd trimesters, courses of immunoglobulin therapy are repeated, to which the administration of interferon is added. In case of detection of pathogenic flora, antibiotics and simultaneous treatment of placental insufficiency are prescribed. With the development of the threat of interruption, the woman is hospitalized.

Immunological causes of miscarriage

To date, it is known that approximately 80% of all "incomprehensible" cases repeated interruptions pregnancy, when genetic, endocrine and anatomical causes were excluded, due to immunological disorders. All immunological disorders are divided into autoimmune and alloimmune, which lead to habitual miscarriage. In the case of an autoimmune process, there is a "hostility" of immunity to the woman's own tissues, that is, antibodies are produced against her own antigens (antiphospholipid, antithyroid, antinuclear autoantibodies). If the production of antibodies by a woman's body is directed to the antigens of the embryo / fetus that he received from his father, they speak of alloimmune disorders.

Antiphospholipid Syndrome

The frequency of APS among the female population reaches 5%, and the cause of habitual miscarriage of APS is 27-42%. The leading complication of this syndrome is thrombosis, the risk of thrombotic complications increases with the progression of pregnancy and after childbirth.

Examination and drug correction of women with APS should begin at the stage of pregnancy planning. A test is performed for lupus anticoagulant and the presence of antiphospholipid antibodies, if it is positive, a repeat of the test is shown after 6 to 8 weeks. In the case of a repeated positive result, treatment should be started even before the onset of pregnancy.

Treatment

APS therapy is prescribed individually (the severity of the activity of the autoimmune process is assessed). Antiplatelet agents (acetylsalicylic acid) are prescribed together with vitamin D and calcium preparations, anticoagulants (enoxaparin, sodium dalteparin), small doses of glucocorticoid hormones (dexamethasone), according to indications of plasmapheresis.

Management of pregnancy

Starting from the first weeks of pregnancy, the activity of the autoimmune process is monitored (lupus anticoagulant, antiphospholipid antibody titer are determined, hemostasiograms are evaluated) and an individual treatment regimen is selected. Against the background of treatment with anticoagulants in the first 3 weeks, OAC is prescribed and the determination of the platelet count, and then the control of the platelet level twice a month.

Fetal ultrasound is performed from 16 weeks and every 3-4 weeks (assessment of fetometric parameters - growth and development of the fetus and the number amniotic fluid). In the 2nd - 3rd trimesters, a study of the functioning of the kidneys and liver (the presence / absence of proteinuria, the level of creatinine, urea and liver enzymes).

Dopplerography to exclude / confirm placental insufficiency, and from 33 weeks, a CTG is performed to assess the condition of the fetus and decide on the timing and method of delivery. In childbirth and on the eve of the control of the hemostasiogram, and in the postpartum period, the course of glucocorticoids is continued for 2 weeks.

Prevention of miscarriage

Non-specific preventive measures for miscarriage include giving up bad habits and abortions, maintaining a healthy lifestyle and a thorough examination of the couple and correcting the identified chronic diseases when planning a pregnancy.

If there are indications of spontaneous abortions and premature births in the anamnesis, the woman is included in the high risk group for recurrent miscarriage, and the spouses are recommended to undergo the following examination:

• blood groups and Rh factor in both spouses;
• consultation with a geneticist and karyotyping of spouses in the presence of a history early miscarriages, antenatal fetal death, the birth of a child with intrauterine developmental anomalies and existing hereditary diseases;
• examination for sexual infections for both spouses, and for a woman for TORCH infection;
• determination of the hormonal status of a woman (FSH, LH, androgens, prolactin, thyroid-stimulating hormones);
• exclude diabetes in a woman;
• in case of detection of anatomical causes of miscarriage, perform surgical correction (removal of myomatous nodes, intrauterine synechia, cervical plastic surgery, etc.);
• pregravid treatment of identified infectious diseases and hormonal correction of endocrine disorders.

Miscarriage is a serious problem that happens to be faced by about 15-25% of couples expecting a baby. Why are some pregnancies doomed to such a sad outcome, and is it possible to deal with this problem, our article will tell.

They talk about miscarriage when, in the period from the moment of conception to 37 weeks, all hopes future mother collapse due to spontaneous miscarriage. It acquires the status of a “familiar” phenomenon when misfortune befalls a pregnant woman 2-3 or more times in a row. Statistics say that habitual miscarriage competes with infertility for the right to be called the most common problem of procreation.

Classification of cases of miscarriage

Depending on the term of termination of pregnancy, there are:

1. Spontaneous abortions. If the miscarriage occurred before 11 weeks, the abortion is considered early. If the misfortune happened between 11 and 21 weeks of gestation, the abortion is late. The interrupt occurs regardless of whether the child is alive or dead.
2. premature birth. Pregnancy is terminated at 22 - 27 weeks, when the child's body weight fluctuates in the range of 0.5 - 1 kg.

There are several stages of abortion, based on which the following types of this condition are distinguished:

• threatened abortion;
• abortion in progress;
• incomplete abortion;
• complete abortion.

In addition, speaking of abortion in general, they mean that it can be failed and infected.

Causes of miscarriage

A great many factors have been found to cause this pathology. Stimulates miscarriage is often not one, but several reasons. Let's list them all.

Reasons depending on future mother:

• endocrine diseases (for example, pathologies related to the health of the ovaries or adrenal glands);
• anatomical features of the female body (for example, an infantile uterus or serious anomalies in its development);
• pathological incompatibility of a woman and a child. It's about about the phenomenon when, on immunological or genetic grounds, the mother organism rejects the embryo/fetus as a potential threat.

Complications that occur during pregnancy:

• preeclampsia, which entails various disorders of cerebral circulation;
• placenta previa or its premature detachment;
• violation of the integrity of the membranes earlier than expected;
• polyhydramnios;
• the presence in the uterus of 2 or more embryos;
• pathological location of the fetus.

Factors not related to gestation:

• acute and chronic infectious diseases;
• pathology of the heart and blood vessels;
• disorders of the functionality of the genitourinary system;
• thrombophilic diseases;
• diseases of the abdominal organs.

Adverse environmental impact:

• bad ecology;
• harmfulness in production related to the profession of a woman;
• physical or mental trauma of the expectant mother;
• bad habits.

It should also be noted that the causes of 27.5 - 63.5% of cases of miscarriage remain unexplained. Pregnant women and the physicians leading them find themselves in such a difficult situation so often that the phenomenon has even been identified as idiopathic (not to be explained) abortion. Drug treatment in these cases is ineffective, and the psychological support of a woman comes to the fore, helping her to endure the pain of loss.

The mechanism of development of pathology

At the basis of self-interruption of intrauterine development of the fetus, a pathological destruction of the connection between cortical and cortico-subcortical factors is hidden, which occurs under the influence of many prerequisites. The prerequisites mean the most complex reflex relationships between mother and child, as well as factors that can affect the nuances and strength of the reflex.

Today, 4 options for the development of pathology have been identified:

1. Termination of pregnancy is possible on the basis of pathological changes in the immune and hormonal balance of the fetoplacental complex. In this case, miscarriage occurs in the early stages (up to 12 weeks).
2. Gestation is interrupted due to active uterine contractions: the fetus is rejected as if labor had begun. This happens mainly closer to the 3rd trimester of the “interesting” position, when the uterus has already undergone morphological and functional metamorphoses.
3. The death and rejection of the fetus occurs under the influence of mutations or genetic disorders.
4. Miscarriage occurs on the basis of isthmic-cervical insufficiency (pathology of the isthmus and cervix) in the middle and at the end of gestation.

Scientists have combined all types of childbearing losses into fetal loss syndrome. The general concept means:

1. One or more miscarriages in a row during a pregnancy of 10 weeks or more.
2. The birth of a dead child in the history of the disease.
3. Neonatal (infant) death.
4. 3 or more self-abortions during the pre-embryonic or early embryonic stage.

Diagnosis of pathology

Due to the fact that miscarriage is considered the result of a combination of the interaction of a number of unfavorable causes, the examination of affected patients is complex. It involves clinical, instrumental and laboratory methods diagnostics, during which the doctor must not only detect the "weak link" during pregnancy, but also examine the state of the patient's reproductive system in order to prevent a recurrence of the misfortune.

Features of the examination before conception

Analyzing the medical history of a woman who has experienced habitual miscarriage, the specialist will pay attention to the hereditary factor, oncological diseases and neuroendocrine disorders. It also remains to be determined whether the patient suffered from genital inflammatory diseases and viral infections in the past, whether she underwent surgery during childbirth, intentional or spontaneous abortions.

Clinical examination is represented by the following procedures:

• examination of a woman by a gynecologist;
• assessment of the patient's skin condition;
• determination of the amount of excess weight according to BMI;
• assessment of the state of the "thyroid gland";
• determination of the frequency of ovulation and the functional viability of the ovaries based on data from rectal temperature and the monthly calendar.

In laboratory and instrumental diagnostics, the following methods are used:

1. Hysterosalpingography. The procedure is relevant in the period from 17 to 23 days of the monthly cycle. With its help, you can examine the body of a woman for the presence of defects and anomalies in the development of internal genital organs, intrauterine synechia, etc.
2. ultrasound. During the procedure, the ovaries are examined, the uterus is checked for the presence of cysts, adenomyosis and polyps.
3. infectious screening. The method involves the examination under a microscope of biological material taken from the urethra, vagina and uterus.
4. Hormonal analysis. Allows you to clarify the level of prolactin, testosterone, cortisol, luteinizing, follicle-stimulating hormones and other important active substances in the patient's blood.

The potential father also undergoes an examination, during which his detailed spermogram is analyzed, the presence of immune and inflammatory factors and specific somatic diseases is clarified.

Features of the examination after conception

If there is a risk of miscarriage in a patient who is in position, she is observed with particular care. The conduct of such a pregnancy is necessarily accompanied by the following research methods:

• regular blood sampling to determine the level of hCG;
• a blood test for DHEA / DHEA sulfate (this is the main steroid hormone in a woman's body, with the participation of which the glands endocrine system produce another 27 hormones);
• periodic consultations with a psychologist.

Symptoms and treatment of miscarriage

The allocation of some blood from the vagina and painful discomfort in the lower abdomen are considered to be the main signs of spontaneous abortion. However, it should be borne in mind that each stage of miscarriage has its own specific manifestations, which means that it requires a special approach to treatment.

Threatened abortion

A woman in position is disturbed by pulling pains in the lower abdomen and in the lower back. If anxiety symptoms are noted in the middle of pregnancy, the pain, as a rule, resembles contractions. Present minor highlight blood. The uterus develops well, its volume corresponds to the gestational age, but there is hypertonicity.

The ultrasound procedure reveals such symptoms of a threatened abortion as an indistinct contour of the fetal egg or detachment of the chorion / placenta in a certain area.

Before prescribing maintenance therapy to a pregnant woman with a threat of miscarriage, the doctor will certainly pay attention to the presence of such concomitant factors as:

• cases of self-abortion in the past;
• age over 34;
• bradycardia;
• the absence of a heartbeat in an embryo with KTR;
• slow growth or its absence in the fetal egg within 10 days;
• an empty fetal egg measuring 15 mm for a gestation period of 7 weeks and 21 mm for a period of 8 weeks;
• the size of the embryo is significantly inferior to the size of the fetal egg;
• reduced levels of hCG;
• low levels of progesterone.

Despite all the warning signs of a threatened abortion, targeted treatment helps keep the pregnancy going. Maintenance therapy in this case is complex: drugs are prescribed at a minimum in scanty doses, mainly focusing on safe procedures in the form of electroanalgesia, acupuncture, electrorelaxation of the uterus and phytoaromatherapy.

Abortion on the go

At this stage of miscarriage, the embryo exfoliates from the uterine endometrium and leaves the uterus through the dilated cervical canal. The pregnant woman feels cramping pain in the abdomen, she has profuse bleeding. Vaginal examination reveals an open cervix with parts of the ovum in it. At 12 weeks gestation, ultrasound shows complete detachment eggs or partial detachment placenta.

tactics further action choose according to the gestational age. So, for a gestation period of up to 16 weeks, the uterus is scraped as a matter of urgency, followed by a laboratory analysis of the torn tissue. With a period of 16 weeks, spontaneous complete rejection of biological material is expected, and only then vacuum cleaning or curettage of the uterus is carried out.

In case of severe bleeding, which can threaten the life of the patient, they act promptly: the embryo is removed from the uterus without waiting for its rejection, and hemodynamics are stabilized. If an immediate operation to curettage the uterus for some reason is not possible, with severe bleeding, the pregnancy is terminated abdominally.

incomplete abortion

The embryo leaves the uterus, but some of its parts remain there. Outwardly, this is manifested by pain of a cramping nature and the release of blood from the vagina, and these symptoms can be of varying degrees of intensity. On examination, the sick doctor determines that the cervix is ​​​​shortened, and the pharynx is open. There is no uterine tone - the organ is soft and does not correspond to the gestation period. On ultrasound in the cavity of the muscular organ, unclear outlines of heterogeneous tissues are found.

In case of incomplete abortion, the uterine cavity is cleaned, removing rejected tissues from there, followed by a laboratory study. They resort to a surgical or medical method of ridding the uterus of parts of the embryo.

The choice in favor of surgery is made in the case of:

• intensive spotting;
• the uterine cavity is open by more than 50 mm;
• body temperature is about 38 0 С.

With a satisfactory condition of the patient and a gestational age of 70 days from the first day of the last menstruation, preference is given to the medical method of cleaning. In case of incomplete abortion, large doses of prostaglandin (from 800 to 1200 mg) are used. Most often they stop at the drug Misoprostol. After 4-6 hours after intravaginal administration, the uterus begins to contract and completely expels the fetal egg. The main advantage of this method is the low percentage of cases of pelvic infection.

Complete abortion

Under the influence of strong uterine contractions, the fetal egg is rejected by the uterine cavity. External signs are either completely absent or are expressed by scanty bleeding and pulling pains in the lower abdomen. Vaginal examination reveals a firm uterus with an open external os. If the patient's condition is satisfactory, then an instrumental examination of the walls of the uterine cavity is not performed.

Missed abortion

In this case, the embryo stops developing, but does not leave the uterus. The patient at this time may increase body temperature and appear ichorus. Subjective sensations"interesting" positions disappear. Ultrasound shows that the size of the embryo lags behind the gestation period. In addition, there are no heartbeats and movements of the embryo. If the diagnosis of a failed abortion is confirmed, an emergency operation is necessary to remove the embryonic or fetal material by surgical or medical means.

Forecast and measures to prevent recurrent miscarriage

The prognosis for the development of pregnancy in the future in a patient whose medical history contains a mark on self-abortion depends on how the previous pregnancy ended. The most favorable prognosis is in women whose pregnancy was terminated due to organic uterine pathology, endocrine or immune factors.

With all the complexity and unpredictability of the phenomenon of habitual miscarriage, you can try to avoid it. After a detailed study of the patient's history, the doctor prescribes a comprehensive treatment, consisting of the use of medications and the implementation of the recommendations of a specialist. An approximate therapeutic complex for the treatment of recurrent miscarriage looks like this:

1. Bed rest and strict diet.
2. The use of sedatives (Sanosan, Diazepam, Phenazepam, herbal tinctures).
3. The use of hormonal drugs. Treatment is effective from the 5th week of gestation until the 28th week inclusive. The most popular drugs are progesterone, gonadotropin, Duphaston and Ethinylestradiol.
4. Use of antibiotics to prevent infection.
5. Tocolytic treatment aimed at suppressing the contractile activity of the uterus.
6. Work to improve the metabolism of the fetoplacental complex, for which the patient is prescribed multivitamin complexes, preparations of ascorbic acid and tocopherol acetate.
7. Operative surgical intervention (in case of urgent need) - a circular suture is applied to the uterus until the 38th week of gestation.

Prevention of miscarriage

Unfortunately, nature cannot be outwitted, and with all the desire of expectant mothers and their attending physicians, cases of habitual miscarriage still occur. The search for methods of getting rid of this pathology continues to this day and indicates that the methods of treatment already found cannot be called 100% effective. However, you can’t give up - a woman must use all the opportunities and chances to become a mother. Therefore, planning pregnancy after the previous one ended in spontaneous abortion is of no small importance.

The patient should consult a doctor for a thorough examination of the state of the body for the presence of diseases in which the course of pregnancy can be complicated, tests to analyze the hormonal background and bacteriological examination of the microflora of the internal genital organs, determine the blood type and Rh factor. In addition, the future father must also undergo a thorough examination.

With an unclear etiology of the causes of miscarriage, a woman can be sent to a specialized hospital for a rigorous analysis of the state of her endocrine and immune system.

How to deal with the problem. Video

Modern methods of therapy for patients with recurrent miscarriage The tactics of managing pregnancy in patients with recurrent miscarriage is an urgent problem of modern obstetrics. Of particular importance is prenatal observation, timely diagnosis and correction of detected disorders in order to prevent miscarriage or the birth of a very premature baby.
It has now been established that 15–20% of all clinically diagnosed pregnancies end in spontaneous termination, of which 75–80% occur within 12 weeks. A similar phenomenon, called "very early pregnancy loss", occurs in the population, probably as a factor of natural selection that prevents the development of genetically abnormal fetuses. With a sporadic miscarriage, the effect of damaging factors is transient, without a violation of the reproductive function of a woman in the future. At the same time, in the group of women who lost their first pregnancy, there is a category of patients (3-5%) in whose body there are endogenous factors that prevent the normal development of the embryo/fetus. Subsequently, this leads to repeated abortions, i.e. to the symptom complex of habitual miscarriage.
Thus, it was found that the risk of pregnancy loss after the first miscarriage is 13–17%, which corresponds to the frequency of sporadic miscarriage in the population, while after 2 previous spontaneous abortions, the risk of losing a desired pregnancy increases by more than 2 times and is 36–38% .
In women who do not have living children, i.e. those suffering from primary recurrent miscarriage, the probability of miscarriage is higher and amounts to 40-45% after the third spontaneous interruption. According to the WHO definition, a habitual miscarriage is considered to be a woman's history of three or more spontaneous abortions in a row up to 22 weeks.
However, given the above risk of losing a desired pregnancy, which increases with the number of failures, most specialists dealing with the problem of miscarriage now come to the conclusion that two consecutive miscarriages are enough to classify a married couple as a habitual miscarriage, followed by a mandatory examination and a set of measures to prepare to pregnancy. In the etiological structure of habitual miscarriage, genetic, anatomical, infectious, endocrine and immunological factors are distinguished. With the exclusion of all of the above causes leading to pregnancy losses, there remains a group of patients whose genesis of recurrent miscarriage is unclear (idiopathic).
The proportion of genetic disorders in the structure of the causes of recurrent miscarriage is relatively small and amounts to 3-6% in women with three or more miscarriages in history.
In couples with recurrent miscarriage, structural changes in chromosomes (intra- and interchromosomal) occur in 3–6% of cases. As a result of meiosis, so-called unbalanced chromosomal rearrangements can form, in which the embryo is either not viable or is a carrier of severe chromosomal pathology.
It is necessary to pay attention to the features of the family history - the presence in the family of congenital anomalies, children with mental retardation, relatives with infertility and miscarriage of unknown origin, cases of perinatal mortality.
It is advisable for couples with 2 or more miscarriages (especially in the absence of healthy children) to conduct a thorough family history, study of the karyotype of spouses, cytogenetic analysis of abortion, genetic counseling and, if indicated - prenatal diagnosis. According to current ideas, in addition to genetic and, in part, infectious causes leading to the laying of an abnormal embryo, the implementation of the damaging effect of other factors (anatomical, endocrine, immunological) consists in creating an unfavorable background for the development of a genetically high-grade fetal egg, which leads to depletion reserve capacity of the chorion and arrest of development (embryogenesis).
A similar phenomenon, in which the death of the embryo precedes the expulsion of the fetal egg, has been called “missed abortion” in the world literature. Critical periods in the first trimester of pregnancy are: 6-8 weeks - the death of the embryo, 10-12 weeks - expulsion of the fetal egg.
Endocrine disorders in the structure of the causes of recurrent miscarriage account for 8–20%. The most significant of them are: hyperandrogenism, luteal phase deficiency (LFP), thyroid dysfunction, diabetes mellitus.
Hyperandrogenism - pathological condition organism, caused by excessive production of androgens synthesized in the adrenal glands and ovaries (adrenogenital syndrome, polycystic ovaries, hyperandrogenism of mixed genesis). Unlike more pronounced clinical cases with infertility, the cause of miscarriage is erased non-classical forms of hyperandrogenism, detected during stress tests or during pregnancy.
With hyperandrogenism of any genesis, abortion most often occurs in the first trimester - according to the type of non-developing pregnancy or anembryony. In 24% of women with hyperandrogenism, branched chorion previa was noted, since implantation occurs mainly in the lower uterus.
If the pregnancy is not terminated in the early stages, the next critical moment is the development of functional isthmic-cervical insufficiency (ICN), which occurs in 40% of women. At later terms (24–26, 28–32 weeks), severe placental insufficiency, intrauterine growth retardation, in some cases leading to antenatal fetal death, may develop. After spontaneous miscarriages in about 1/3 of patients with hyperandrogenism, hormonal disorders are aggravated, which not only worsens the outcome of a subsequent pregnancy, but can also lead to secondary infertility, menstrual dysfunction up to amenorrhea, and increased hirsutism. In this regard, timely diagnosis and correction of hyperandrogenism through the selection of adequate therapy is the prevention of further reproductive disorders, in particular, miscarriage. In case of adrenal hyperandrogenism, preparation begins with a dexamethasone test: from the 5th day of the menstrual cycle, dexamethasone is prescribed at a dose of 0.5 mg (1 tablet) 4 times a day for 3 days, then the dose is reduced under the control of androgen levels. When pregnancy occurs, treatment with dexamethasone should be continued throughout the entire gestational period at low doses - ?-1/2 tablets daily. With hyperandrogenism of ovarian origin, the treatment is longer: for 2-3 months, gestagens are prescribed to prepare the endometrium for implantation - mainly Duphaston at a daily dose of 20 mg, then ovulation is stimulated with clostilbegit with the simultaneous administration of dexamethasone. Duphaston (dydrogesterone), being a structural analogue of natural progesterone, has advantages over other progestogen drugs, since it does not have androgenic and corticoid effects, does not disrupt lipid and carbohydrate metabolism, which is especially important for patients with hyperandrogenism and metabolic disorders. If there is no effect within 3 months, you should take a break, and then repeat the course of treatment, starting with progestins (Dufaston). After the second unsuccessful attempt, surgical treatment is indicated - wedge resection of polycystic ovaries, preferably by laparoscopic access. Hyperandrogenism of mixed origin requires longer preparation and begins with normalization metabolic processes- correction of disorders of fat metabolism. In the case of pronounced menstrual irregularities, the appointment of hormonal contraception with Diane-35 is indicated, after which ovulation is stimulated with clostilbegit while taking dexamethasone in the conception cycle.
From the first weeks of pregnancy, it is necessary to prevent placental insufficiency by prescribing metabolic therapy. In this group of patients, pregnancy is often complicated by hypertension and the development of preeclampsia, and therefore it is necessary to control the level blood pressure, consumed salt and liquid, diet therapy. The anatomical causes of habitual miscarriage include: congenital anomalies in the development of the uterus (double, bicornuate, saddle-shaped, unicornuate uterus, partial or complete intrauterine septum) and acquired anatomical defects - intrauterine synechia (Asherman's syndrome), submucosal uterine myoma. The frequency of anatomical abnormalities in patients with recurrent miscarriage ranges from 3–16%, which is probably due to the different diagnostic capabilities of research centers. Termination of pregnancy with anatomical abnormalities of the uterus may be associated with unsuccessful implantation of the fetal egg (often on the intrauterine septum, near the submucous node of the myoma), insufficiently developed vascularization and endometrial reception, close spatial relationships, often concomitant with ICI, hormonal disorders (hypoestrogenism, luteal phase deficiency) . Currently, hysterosalpingography, hysteroscopy are performed to make a diagnosis; in some difficult cases, nuclear magnetic resonance of the pelvic organs is used to verify the diagnosis. Surgical treatment most effective in the presence of an intrauterine septum and synechia. Hysteroresectoscopy is preferred. The frequency of subsequent miscarriages in this group of women is 10% compared with 90% before surgery. Removal of the intrauterine septum is performed with a hysteroresectoscope with mandatory control from the abdominal cavity over the depth of the dissection using a laparoscope. When managing pregnancy in such patients in the early stages, bed or semi-bed rest, the appointment of antispasmodic (no-shpa) and herbal sedatives, Duphaston therapy up to 16–20 weeks of gestation in daily doses of 20–30 mg are advisable. It is mandatory to prescribe a complex of metabolic therapy to normalize metabolic processes and prevent fetal malnutrition, as well as drugs that improve blood circulation in the vessels of the placenta - Essentiale Forte, Actovegin, Troxevasin.
Recent studies have shown that in women with recurrent miscarriage, bacterial and viral colonization of the endometrium is significantly more common than in women with a normal obstetric history. So, outside of pregnancy, the diagnosis of chronic endometritis was histologically verified in 73% of patients, in 87% of cases persistence of opportunistic microorganisms in the endometrium is observed.
Mixed viral infection (herpes simplex virus, Coxsackie A, Coxsackie B, enteroviruses 68-71, cytomegalovirus) is combined with the persistence of 2-3 or more anaerobic and aerobic bacteria.
The persistence of microorganisms is characterized by the involvement of mononuclear phagocytes, natural killers, T-helpers, synthesizing various cytokines, into the focus of chronic inflammation. Apparently, such a state of the endometrium prevents the creation of local immunosuppression in the preimplantation period, which is necessary to form a protective barrier and prevent rejection of a half-foreign fetus. Examination outside of pregnancy of patients with recurrent miscarriage must necessarily include bacteriological examination of the separated cervical canal and, if pathogenic microorganisms are detected, determination of their sensitivity to antibiotics. Antibacterial therapy, selected individually, helps to normalize the immunological processes in the endometrium, create favorable conditions for subsequent implantation and prevent infectious damage to the embryo. It is advisable to combine antibiotic therapy with metronidazole or clindamycin, which affect the anaerobic flora.
In the management of patients with persistent viral infection, the focus is on the normalization of immune processes to avoid exacerbations during pregnancy. Danger to the fetus is only the first meeting of the body with herpes simplex and cytomegalovirus viruses in seronegative women.
Outside of pregnancy with frequent exacerbations herpetic infection an anti-relapse course is prescribed with antiviral drugs: acyclovir, famciclovir, valaciclovir. Immunomodulatory drugs are used - larifan, ridostin, derinat, imunofan.
In the first trimester of pregnancy with exacerbation viral infection it is advisable to intravenously drip immunoglobulin at a dose of 25.0 ml every other day three times or the drug octagam at a dose of 2.5-5 g (50-100 ml). In virus carriers with frequent exacerbations, it is necessary to conduct such courses in the II and III trimesters of pregnancy. It is now known that about 80% of all previously unexplained cases of recurrent pregnancy losses are associated with immunological disorders. The immune system, evolutionarily designed to recognize and eliminate foreign antigens, often causes an inadequate response of the mother's body to the development of pregnancy. There are autoimmune and alloimmune disorders leading to the rejection of the embryo/fetus.
In alloimmune disorders, the woman's immune response is directed against the child's antigens received from the father and potentially foreign to the mother's body. Currently, alloimmune processes leading to fetal rejection include: the presence of an increased number of common antigens of the HLA system in spouses (family marriages); low level blocking antibodies in the mother's serum; increased content of natural killers in the endometrium and peripheral blood of the mother both outside and during pregnancy. In autoimmune processes, the target for the aggression of the immune system is the mother's own tissues. In this situation, the fetus suffers a second time as a result of damage to the vessels of the developing placenta. Of the autoimmune disorders that cause obstetric pathology, the antiphospholipid syndrome (APS) is generally recognized. The incidence of APS among patients with recurrent miscarriage is 27-42%, and without treatment, embryo/fetal death is observed in 90-95% of women with autoantibodies to phospholipids. Microthrombosis in the vessels of the developing placenta disrupts its function, which leads to placental insufficiency and, in some cases, ends in the death of the embryo/fetus. The world literature describes the following main areas drug therapy patients with APS:
- corticosteroids in combination with anticoagulants and antiplatelet agents;
- the appointment of corticosteroids in conjunction with acetylsalicylic acid;
– correction of the hemostasis system with anticoagulants and antiaggregants;
- monotherapy with acetylsalicylic acid;
- monotherapy with heparin;
- high doses of immunoglobulin intravenously. According to foreign researchers, when using various kinds drug therapy, the highest positive results in prolonging pregnancy were noted with the use of high doses of immunoglobulins, the lowest - with monotherapy with acetylsalicylic acid (42%).
Without therapy, the birth of viable children is observed only in 6% of cases.
We consider the optimal scheme for managing patients with antiphospholipid syndrome, which includes the following main areas:
low-dose corticosteroid therapy (5–10 mg per prednisolone); correction of hemostasiological disorders with antiplatelet agents and anticoagulants according to indications (preference is given to low molecular weight heparins); prevention of placental insufficiency - metabolic therapy; prevention of reactivation of a viral infection in the carriage of HSV II and CMV.
Complex therapy with corticosteroids, immunoglobulins, anticoagulants and antiplatelet agents does not always lead to the desired effect due to the presence of drug intolerance in some cases, insufficient effectiveness of the doses used, and also due to side effects that occur. In addition, there remains a category of patients resistant to drug therapy.
Such patients are recommended to conduct sessions of therapeutic plasmapheresis. A number of specific effects of plasmapheresis - detoxification, rheocorrection, immunocorrection, increased sensitivity to endogenous and drug substances - creates the prerequisites for its use in patients with antiphospholipid syndrome.
Summarizing the above data, it should be noted that miscarriage is a polyetiological problem that is difficult, and sometimes impossible, to solve during pregnancy. In this regard, a comprehensive examination of patients with 2 or more miscarriages in history before the desired pregnancy is necessary.
Examination outside of pregnancy should include:
Evaluation of anamnestic data
Carrying out hysterosalpingography to detect abnormalities in the development of the uterus
Hormonal examination - functional diagnostic tests
ultrasound
Bacteriological, virological research
Blood coagulation assessment
Definition of autoantibodies
HLA typing
According to the indications - medical genetic counseling and analysis of the husband's spermogram.
Correction of the identified violations should be started in a timely manner and carried out even before conception.
When pregnancy occurs from an early date, it is necessary to prescribe antispasmodic drugs, of which drotaverine is the most effective and safe (both for oral and parenteral administration).
The use of Duphaston, previously used to correct hormonal disorders (luteal phase deficiency, in the treatment of hyperandrogenism, etc.), has now acquired a new meaning in connection with the described immunocorrective effect of this drug. Thus, it has been established that Duphaston modulates the immune response of a pregnant woman from fetal rejection to its protection by ensuring sufficient activation of progesterone receptors and subsequent induction of PIBF (progesterone inducible blocking factor). PIBF is a 35 kilodalton protein produced by CD56 cells and peripheral blood mononuclear cells after progesterone receptor activation. PIBF, in turn, determines: a decrease in the activity of alloimmune reactions, including the suppression of natural killers and the provision of an immune response according to the type of T-helper type 2 prevalence. Thus, the appointment of Dufaston at a dose of 20 mg per day in the early stages of gestation has an immunomodulatory effect and prevents embryo rejection reactions. Patients with habitual miscarriage are a risk group for the development of placental insufficiency, fetal malnutrition, chronic intrauterine hypoxia fetus. In this regard, from an early date, it is advisable, in addition to pathogenetic and symptomatic therapy, to carry out a set of measures aimed at preventing placental insufficiency, as well as assessing the functioning of the fetoplacental complex. Our experience shows that with a preliminary examination and timely adequate treatment, careful monitoring of the gestational process in patients with recurrent miscarriage, the birth of full-term viable children is 98%.
Professor A.A. Agadzhanova
Scientific Center for Obstetrics, Gynecology and Perinatology of the Russian Academy of Medical Sciences

The sad stories of patients suffering from habitual miscarriage look about the same. Their pregnancies are interrupted one after another - at about the same "critical" period. After several unsuccessful attempts to bear a child, a woman develops a feeling of hopelessness, self-doubt, and sometimes a sense of guilt. Such a psychological state only exacerbates the situation and may become one of the causes of the following miscarriages. Can a woman get out of this vicious circle? Much of it depends on her.

What is habitual miscarriage?

\ To begin with, let's define the subject of our conversation. Russian gynecologists diagnose "recurrent miscarriage" in the event that the patient has at least two spontaneous abortions for up to 37 weeks. In some other countries (for example, in the USA), miscarriage is considered habitual, which has repeated at least three times.

Most often, pregnancy is terminated in the first trimester. Before 28 weeks, a miscarriage occurs, and after this period - premature birth, in which the child has every chance of surviving. This article will focus on cases of habitual termination of pregnancy for up to 28 weeks.

Causes of early miscarriage

If the cause of a single miscarriage is usually any “external” factors: unfavorable living conditions for pregnancy (difficult family relationships, busy work schedule, etc.), stress, excessive physical activity (for example, weight lifting), some biological factors (for example, before the age of 18 and after 35 years), then in the case of habitual miscarriage, aspects related to the woman's health most often come to the fore. It should also be noted that this condition is never due to any one reason: there are always at least two factors leading to a sad outcome.

To identify the causes of recurrent miscarriage, the doctor will ask if the woman has any common diseases and also clarify gynecological history, including information about past inflammatory diseases, induced abortions and other interventions, the number of miscarriages, the timing of termination of pregnancies, prescribed treatment, etc.

What tests are needed for miscarriage?

But only an additional medical examination will help to dot the “i”, which, depending on the specific situation, may consist of various stages:

1. Ultrasonography reproductive system women. With the help of this study, the state of the ovaries is clarified, various changes in the structure of the uterus (malformations, tumors, endometriosis, adhesions in the uterine cavity), signs of chronic inflammation of the uterine cavity mucosa can be detected. If cervical insufficiency is suspected, an ultrasound scan measures the diameter of the internal cervical os in the second phase of the menstrual cycle.
2. Hysterosalpingography 1 and hysteroscopy 2 are carried out mainly with suspicion of intrauterine pathology, malformations of the uterus.
3. Rectal temperature measurement(i.e. rectal temperature) before pregnancy for 2 to 3 menstrual cycles is the easiest way to get an idea of ​​the hormonal function of the ovaries. Many women who suffer from recurrent miscarriage show insufficiency of the second phase of the menstrual cycle. This condition can be manifested either by an insufficient rise in rectal temperature (the difference in the first and second phases of the cycle is less than 0.4 - 0.5 degrees) or the duration of this phase is less than 10 - 12 days.
4. A blood test aimed at determining the level of various hormones. The study of the level of sex hormones and hormones that regulate the functioning of the ovaries is carried out twice: the first time - in the middle of the first phase of the menstrual-ovarian cycle (on average on the 7th - 8th day from the onset of menstruation), the second time - in the middle of the second phase (on average - on the 20th - 24th day). Hormonal disorders associated with a change in the functioning of the ovaries can cause early miscarriages for up to 16 weeks, since at a later date the placenta almost completely takes over the provision of hormonal levels that favor the normal course of pregnancy. Approximately one third of all patients with habitual miscarriage have hyperandrogenism (an increase in the level of male sex hormones in the female body), which can lead to isthmic-cervical insufficiency. It is very important to investigate not only the female and male sex hormones released in the female body, but also the thyroid hormones that have a direct effect on tissue laying, correct formation embryo and its development.
5. A blood test for a viral infection (herpes, cytomegalovirus), a study of the genital tract for sexually transmitted infections (chlamydia, mycoplasma, ureaplasma, herpes, cytomegalovirus, etc.) in a married couple. The genital tract is also being examined for conditionally pathogenic flora, which, under certain conditions, can cause infection of the fetus and lead to its death. Very often, as a result of this study, a combination of 2-3 infections is detected. Sometimes, in order to exclude chronic endometritis (inflammation of the mucous membrane lining the inner surface of the uterus), an endometrial biopsy is performed on the 7th - 9th day of the menstrual cycle, while a piece of the mucous membrane is plucked off, its structure and sterility are examined.
6. Blood tests that detect immune disorders which sometimes cause miscarriage. These studies can be very diverse: the search for antibodies to the cardiolipin antigen, to DNA, to blood cells, etc.
7. Study of the blood coagulation system. Doctors recommend refraining from pregnancy until stable normalization of blood coagulation, and during pregnancy, it is regularly monitored.
8. If the pregnancy is terminated before 8 weeks, the couple needs genetics consultation, since it is highly likely that the miscarriage occurred due to the genetic imperfection of the embryo. Genetic anomalies in the development of the embryo can be hereditary, passed down from generation to generation, or arise under the influence of various environmental factors. Their appearance can be assumed in closely related marriages, in the presence of genetic pathology on the maternal or paternal side, living in an area with an unfavorable radioactive background, contact with harmful chemicals (for example, mercury, some solvents), use of certain teratogenic medicines(for example, cytostatics, certain hormonal drugs, including contraceptives), as well as with a viral infection (rubella, influenza, cytomegalovirus infection, herpes) transferred in the early stages of pregnancy.
9. Men may be recommended semen analysis, since sometimes the cause of the death of the embryo may be defective spermatozoa.
10. Conducted if necessary consultations with an endocrinologist, therapist, since the cause of miscarriages can also be somatic diseases that are not associated with the female genital area, for example, diabetes mellitus, hypertension.

How to get pregnant after a miscarriage?

Constant emotional stress due to repeated miscarriages not only adversely affects the psychological state of a woman, but also worsens her physical health up to the development of infertility. Therefore, in such a situation, it can be advised to temporarily stop trying to become a mother and relax, restore peace of mind - for example, go on vacation and change the situation. In some cases, you have to resort to the help of a psychotherapist and sedative drugs that help relieve anxiety. Sometimes light sedatives are prescribed even after the onset of pregnancy in order to relieve a woman's mental stress during “critical” periods.

It is very important not to enter into next pregnancy without examination and without preliminary preparation, since the risk of repeated losses is great, especially since during the next pregnancy it is more difficult to find out the cause of previous miscarriages.

For at least 6 months (preferably 1 year) after the last miscarriage, partners should use contraceptives. Firstly, it will help the woman to recover, calm down, and secondly, during this time she will be able to be examined, find out what is the cause of repeated failures, and undergo the necessary rehabilitation treatment. Such targeted preparation leads to a reduction in the amount of drug treatment during pregnancy, which is important for the fetus. With minimal signs of a threat of interruption, as well as in those periods when previous miscarriages occurred, hospitalization is necessary. During pregnancy, it is recommended to avoid physical activity.

Unfortunately, it happens that women seek medical help only after several unsuccessful pregnancies. No need to try alone to fight with nature and tempt fate. Immediately after the first failure that has befallen a woman, she needs to turn to specialists and begin to be examined in order to avoid a repetition of the tragedy if possible, because the modern arsenal of medical care in most such cases ensures the safe birth of a full-term baby.

According to statistics, miscarriage is recorded in 10-25% of pregnant women.

The cause of miscarriage can be various diseases that are difficult to cure or have become chronic. However, these diseases do not apply to the sexual sphere. An important feature this kind of pathology is the unpredictability of the process, since for each specific pregnancy it is difficult to determine the true cause of abortion. Indeed, at the same time, the body of a pregnant woman is influenced by many different factors that can act covertly or explicitly. The outcome of pregnancy in case of habitual miscarriage is largely determined by the ongoing therapy. With three or more spontaneous miscarriages at gestational ages up to 20 weeks of gestation, an obstetrician-gynecologist diagnoses habitual miscarriage. This pathology occurs in 1% of all pregnant women.

After the fertilized ovum is “located” in the uterine cavity, the complex process of its engraftment there begins - implantation. The future baby first develops from a fetal egg, then becomes an embryo, then it is called a fetus that grows and develops during pregnancy. Unfortunately, at any stage of bearing a child, a woman may encounter such pathology of pregnancy as her miscarriage.

Miscarriage is the termination of pregnancy between the time of conception and the 37th week.

Risk of primary miscarriage

Doctors note a certain pattern: the risk of miscarriage after two failures increases by 24%, after three - 30%, after four - 40%.

In case of miscarriage, a complete or incomplete (the fetal egg exfoliated from the uterine wall, but remained in its cavity and did not come out) miscarriage occurs in the period up to 22 weeks. At a later date, in the period of 22-37 weeks, spontaneous abortion is called premature birth, and an immature but viable baby is born. Its mass ranges from 500 to 2500 g. Premature, prematurely born children are immature. Their death is often noted. In surviving children, malformations are often recorded. The concept of prematurity, in addition to the short term of pregnancy, includes low birth weight of the fetus, on average from 500 to 2500 g, as well as signs of physical immaturity in the fetus. Only by a combination of these three signs can a newborn be considered premature.

With the development of miscarriage, certain risk factors are indicated.

Modern advances in medicine and new technologies, the timeliness and quality of medical care make it possible to avoid serious complications and prevent premature termination of pregnancy.

A woman with a first trimester miscarriage should undergo a long-term examination before the expected pregnancy and during pregnancy to identify true reason miscarriage. Very a difficult situation develops with spontaneous miscarriage against the background normal flow pregnancy. In such cases, the woman and her doctor can do nothing to prevent such a course of events.

The most common factor in the development of premature termination of pregnancy are fetal chromosomal abnormalities. Chromosomes are microscopic elongated structures located in the internal structure of cells. Chromosomes contain genetic material that defines all the properties that are characteristic of each “person: eye color, hair, height, weight parameters, etc. There are 23 pairs of chromosomes in the structure of the human genetic code, 46 in total, with one part inherited from the mother organism, and the second - from the father. Two chromosomes in each set are called sex chromosomes and determine the sex of a person (XX chromosomes determine the female sex, XY chromosomes determine the male sex), while the other chromosomes carry the rest of the genetic information about the whole organism and are called somatic.

It has been established that about 70% of all miscarriages in early pregnancy are due to abnormalities of the somatic chromosomes in the fetus, while most of the chromosomal abnormalities of the developing fetus occurred due to the participation of a defective egg or sperm in the process of fertilization. This is due to the biological process of division, when the egg and sperm in the process of their preliminary maturation divide in order to form mature germ cells in which the set of chromosomes is 23. In other cases, eggs or spermatozoa are formed with an insufficient (22) or excessive (24) set chromosomes. In such cases, the formed embryo will develop with a chromosomal abnormality, leading to a miscarriage.

Trisomy can be considered the most common chromosomal defect, while the embryo is formed by the fusion of a germ cell with chromosome set 24, as a result of which the set of fetal chromosomes is not 46 (23 + 23), as it should be, but 47 (24 + 23) chromosomes . Most trisomies involving somatic chromosomes lead to the development of a fetus with malformations that are incompatible with life, which is why spontaneous miscarriage occurs in early pregnancy. In rare cases, a fetus with a similar developmental anomaly lives to a long time.

An example of the most well-known developmental anomaly caused by trisomy is Down's disease (represented by trisomy on chromosome 21).

A woman's age plays an important role in the occurrence of chromosomal disorders. And recent studies show that the age of the father plays an equally important role, the risk of genetic abnormalities increases with the age of the father over 40 years.
As a solution to this problem, married couples, where at least one partner is diagnosed with congenital genetic diseases, a mandatory consultation with a geneticist is offered. In certain cases, it is proposed to carry out IVF (in vitro fertilization - artificial insemination in vitro) with a donor egg or sperm, which directly depends on which of the partners revealed such chromosomal disorders.

Causes of primary miscarriage

There can be many reasons for such violations. The process of conceiving and carrying a baby is complex and fragile, it involves a large number of interrelated factors, one of which is endocrine (hormonal). The female body maintains a certain hormonal background so that the baby can develop correctly at each stage of its intrauterine development. If for some reason the body of the expectant mother begins to produce hormones incorrectly, then hormonal imbalances cause a threat of abortion.

Never take hormones on your own. Their intake can seriously disrupt the reproductive function.

The following congenital or life-acquired lesions of the uterus can threaten the course of pregnancy.

• Anatomical malformations of the uterus - duplication of the uterus, saddle uterus, bicornuate uterus, unicornuate uterus, partial or complete uterine septum in the cavity - are congenital. Most often, they prevent the fetal egg from successfully implanting (for example, the egg "sits" on the septum, which is not able to perform the functions of the inner layer of the uterus), which is why a miscarriage occurs.
• Chronic endometritis - inflammation of the mucous layer of the uterus - the endometrium. As you remember from the section that provides information on the anatomy and physiology of a woman, the endometrium has an important reproductive function, but only as long as it is “healthy”. Prolonged inflammation changes the nature of the mucous layer and disrupts its functionality. It will not be easy for a fetal egg to attach and grow and develop normally on such an endometrium, which can lead to pregnancy loss.
• Polyps and hyperplasia of the endometrium - the growth of the mucous membrane of the uterine cavity - the endometrium. This pathology can also prevent the implantation of the embryo.
• Intrauterine synechia - adhesions between the walls in the uterine cavity, which do not allow the fertilized egg to move, implant and develop. Synechia most often occurs as a result of mechanical trauma to the uterine cavity or inflammatory diseases.
• Uterine fibroids are benign tumor processes that occur in the muscular layer of the uterus - myometrium. Fibroids can cause miscarriage if the fetal egg is implanted next to the myoma node, which has broken the tissue of the internal cavity of the uterus, “takes over” the blood flow and can grow towards the fetal egg.
• Isthmic-cervical insufficiency. It is considered the most common cause of perinatal losses in the second trimester of pregnancy (13-20%). The cervix shortens with subsequent dilatation, which leads to pregnancy loss. Typically, isthmic-cervical insufficiency occurs in women whose cervix has been damaged earlier (abortion, rupture in childbirth, etc.), has a congenital malformation, or cannot cope with the increased load during pregnancy ( large fruit, polyhydramnios, multiple pregnancy and so on.).

Some women have a congenital predisposition to thrombosis (blood clotting, the formation of blood clots in the vessels), which makes it difficult for the implantation of the fetal egg and prevents normal blood flow between the placenta, baby and mother.

The expectant mother often does not know at all about her pathology before pregnancy, since her hemostasis system coped well with its functions before pregnancy, that is, without the “double” load that appears with the task of bearing a baby.

There are other causes of miscarriage that need to be diagnosed for timely prevention and treatment. Methods of correction will depend on the identified cause.

The cause of habitual miscarriage can also be normal chromosomes, which do not give problems in the development of both partners, but carry a hidden carriage of chromosomal disorders, which affect the developmental anomalies of the fetus. In such a situation, both parents should have their blood tested for a karyotype in order to identify such chromosomal abnormalities (carriage of non-manifesting chromosomal abnormalities). During this examination, based on the results of karyotyping, a probable assessment of the course of a subsequent pregnancy is determined, and the examination cannot give a 100% guarantee of possible anomalies.

Chromosomal abnormalities are diverse, they can also be the cause of non-developing pregnancy. In this case, only fetal membranes are formed, while the fetus itself may not be. It is noted that the fetal egg is either formed initially, or it stopped its further development in the early stages. For this, in the early stages, the cessation of the characteristic symptoms of pregnancy is characteristic, at the same time often appear dark brown discharge from the vagina. Ultrasound can reliably determine the absence of a fetal egg.

Miscarriage in the second trimester of pregnancy is mainly due to abnormalities in the structure of the uterus (such as an irregular shape of the uterus, an additional uterine horn, its saddle shape, the presence of a septum or weakening of the cervix's holding capacity, the opening of which leads to premature birth). In this case, possible causes of miscarriage in the later stages may be infection of the mother (inflammatory diseases of the appendages and uterus) or chromosomal abnormalities of the fetus. According to statistics, chromosomal abnormalities are the cause of miscarriage in the second trimester of pregnancy in 20% of cases.

Symptoms and signs of primary miscarriage

A characteristic symptom of miscarriage is bleeding. Bloody discharge from the vagina with spontaneous miscarriage usually begins suddenly. In some cases, a miscarriage is preceded by pulling pain in the lower abdomen, which resembles pain before menstruation. Together with the release of blood from the genital tract, with the onset of spontaneous miscarriage, the following symptoms are often observed: general weakness, malaise, fever, a decrease in nausea that was present before, emotional tension.

But not all cases of spotting in early pregnancy end in spontaneous miscarriage. In case of bleeding from the vagina, a woman should consult a doctor. Only a doctor will be able to conduct a proper examination, determine the condition of the fetus, find out if the cervix is ​​dilated and select the right treatment aimed at maintaining pregnancy.

If bloody discharge from the genital tract is detected in the hospital, a vaginal examination is performed first. If the miscarriage is the first and occurred in the first trimester of pregnancy, then the study is carried out shallowly. In the event of a miscarriage in the second trimester or two or more spontaneous abortions in the first trimester of pregnancy, it becomes necessary complete examination.

In this case, the course of a complete examination includes a certain set of examinations:

1. blood tests for chromosomal abnormalities in both parents (clarification of the karyotype) and the determination of hormonal and immunological changes in the blood of the mother;
2. testing for chromosomal abnormalities of aborted tissues (it is possible to determine if these tissues are available - either the woman herself saved them, or they were removed after curettage of the uterus in a hospital);
3. ultrasound examination of the uterus and hysteroscopy (examination of the uterine cavity using a video camera that is inserted through the cervix and displays a picture on the screen);
4. hysterosalpingography (X-ray examination of the uterus;
5. biopsy of the endometrium (inner layer) of the uterus. This manipulation involves taking a small piece of the uterine mucosa, after which a hormonal examination of the tissue is performed.

Treatment and prevention of primary miscarriage

If pregnancy is threatened by endocrine disorders in a woman, then after laboratory tests, the doctor prescribes hormone therapy. In order to prevent unwanted surges in hormones, medications can be prescribed even before pregnancy, with subsequent adjustment of the dosage and drugs already during pregnancy. In the case of hormone therapy, the condition of the expectant mother is always monitored and appropriate laboratory tests (analyzes) are performed.

If miscarriage is due to uterine factors, then appropriate treatment is carried out a few months before the conception of the baby, as it requires surgical intervention. During the operation, synechiae are dissected, polyps of the uterine cavity are removed, fibroids that interfere with the course of pregnancy are removed. Medications before pregnancy treat infections that contribute to the development of endometritis. Isthmic-cervical insufficiency during pregnancy is corrected surgically. Most often, the doctor prescribes suturing the cervix (for a period of 13-27 weeks) in the event of its insufficiency - the cervix begins to shorten, become softer, the internal or external pharynx opens. The stitches are removed at 37 weeks of gestation. A woman with a sutured cervix is ​​shown a sparing physical regimen, the absence of psychological stress, since even on a sutured cervix, amniotic fluid may leak.

In addition to suturing the cervix, a less traumatic intervention is used - putting a Meyer ring on the cervix ( obstetric pessary), also protecting the neck from further disclosure.

The doctor will suggest the most suitable method for each specific situation.

Do not forget that not only ultrasound data is important, but also information obtained during a vaginal examination, since the neck can be not only shortened, but also softened.

For the prevention and treatment of problems associated with the hemostasis system of the expectant mother, the doctor will prescribe laboratory blood tests (mutations of the hemostasis system, coagulogram, D-dimer, etc.). Based on the published survey results, it can be applied drug treatment(tablets, injections), which improves blood flow. Expectant mothers with impaired venous blood flow are recommended to wear therapeutic compression stockings.

There can be many reasons for miscarriage. We did not mention severe extragenital pathologies (diseases that are not related to the genital area), in which it is difficult to bear a child. It is possible that for a particular woman, not one reason “works” for her condition, but several factors at once, which, overlapping each other, give such a pathology.

It is very important that a woman with a miscarriage (three or more losses in history) be examined and undergo medical preparation BEFORE the upcoming pregnancy in order to avoid this complication.

Treatment of such a pathology is extremely difficult and requires a strictly individual approach.

Most women do not need treatment as such immediately after a spontaneous miscarriage in the early stages. The uterus is gradually and completely self-cleansing, as it happens during menstruation. However, in some cases of incomplete miscarriage (partially the remains of the fetal egg remain in the uterine cavity) and when the cervix is ​​bent, it becomes necessary to scrape the uterine cavity. Such manipulation is also required in case of intense and non-stop bleeding, as well as in cases of a threat of the development of an infectious process, or if, according to ultrasound, remnants of the membranes are found in the uterus.

Anomalies in the structure of the uterus is one of the main causes of habitual miscarriage (the cause is in 10-15% of cases of repeated miscarriage in both the first and second trimesters of pregnancy). Such anomalies of the structure include: the irregular shape of the uterus, the presence of a septum in the uterine cavity, benign neoplasms that deform the uterine cavity (myomas, fibromas, fibromyomas) or scars from previous surgical interventions (caesarean section, removal of fibromatous nodes). As a result of such violations, problems arise for the growth and development of the fetus. The solution in such cases is the elimination of possible structural disorders and very close monitoring during pregnancy.

A certain weakness of the muscular ring of the cervix plays an equally important role in habitual miscarriage, while the most typical term for termination of pregnancy for this reason is 16-18 weeks of pregnancy. Initially, the weakness of the muscular ring of the cervix can be congenital, and can also be the result of medical interventions - traumatic injuries of the muscular ring of the cervix (as a result of abortions, purges, ruptures of the cervix during childbirth) or a certain kind of hormonal disorders (in particular, an increase in the level of male sex hormones). The problem can be solved by applying a special suture around the cervix at the beginning of a subsequent pregnancy. The procedure is called "cervical seclage".

A major cause of recurrent miscarriage is hormonal imbalance. Thus, ongoing studies have revealed that low progesterone levels are extremely important in maintaining pregnancy in the early stages. It is the deficiency of this hormone that is the cause of early termination of pregnancy in 40% of cases. The modern pharmaceutical market has been significantly replenished with drugs similar to the hormone progesterone. They are called progestins. The molecules of such synthetic substances are very similar to progesterone, but they also have a number of differences due to modification. Such drugs are used in hormone replacement therapy in cases of corpus luteum insufficiency, although each of them has a certain range of disadvantages and side effects. Currently, there is only one drug that is completely identical to natural progesterone - utrogestan. The drug is very convenient to use - it can be taken orally and injected into the vagina. Moreover, the vaginal route of administration has a large number of advantages, since, being absorbed into the vagina, progesterone immediately enters the uterine bloodstream, so progesterone secretion is simulated corpus luteum. To maintain the luteal phase, micronized progesterone is prescribed at a dose of 2-3 capsules per day. If, against the background of the use of utrozhestan, pregnancy develops safely, then it is continued, and the dose is increased to 10 capsules (which is determined by the gynecologist). With the course of pregnancy, the dosage of the drug is gradually reduced. The drug is reasonably used until the 20th week of pregnancy.

A pronounced hormonal disorder may be the result of polycystic altered ovaries, resulting in multiple cystic formations in the body of the ovaries. The reasons for recurrent non-violence in such cases are not well understood. Habitual miscarriage is often the result of immune disorders in the body of the mother and fetus. This is due to the specific feature of the body to produce antibodies to fight penetrating infections. However, the body can also produce antibodies against the body's own cells (autoantibodies), which can attack the body's own tissues, causing health problems and premature termination of pregnancy. These autoimmune disorders are responsible for 3-15% of cases of recurrent miscarriage. In such a situation, it is first necessary to measure the existing level of antibodies with the help of special blood tests. Treatment involves the use of small doses of aspirin and drugs that thin the blood (heparin), which leads to the possibility of carrying a healthy baby.

Modern medicine draws attention to a new genetic anomaly - a Leiden mutation of factor V, which affects blood clotting. This genetic feature may also play important role in recurrent miscarriage. Treatment of this kind of disorders is currently not fully developed.

A special place among the causes of habitual miscarriage is occupied by asymptomatic infectious processes in the genitals. It is possible to prevent premature termination of pregnancy by routine testing of partners for infections, including women, before a planned pregnancy. The main pathogens that cause habitual miscarriage are mycoplasmas and ureaplasmas. Antibiotics are used to treat such infections: ofloxin, vibromycin, doxycycline. The treatment provided must be performed by both partners. A control examination for the presence of these pathogens is performed one month after the end of antibiotic therapy. In this case, a combination of local and general treatment is extremely necessary. Locally, it is better to use broad-spectrum drugs that act on several pathogens at the same time.

In the event that the causes of repeated miscarriage cannot be detected even after a comprehensive examination, the spouses should not lose hope. It has been statistically established that in 65% of cases after miscarriage, spouses have a successful subsequent pregnancy. To do this, it is important to strictly follow the prescriptions of doctors, namely, to take a proper break between pregnancies. For a complete physiological recovery after a spontaneous miscarriage, it takes from several weeks to a month, depending on how long the pregnancy was terminated. For example, certain pregnancy hormones remain in the blood for one or two months after a miscarriage, and menstruation in most cases begins 4-6 weeks after the termination of pregnancy. But psycho-emotional recovery often takes much longer.

It should be remembered that the observation of a pregnant woman with habitual miscarriage should be carried out weekly, and if necessary, more often, for which hospitalization is carried out. After establishing the fact of pregnancy, an ultrasound examination should be performed to confirm the uterine form, and then every two weeks until the period at which the interruption occurred previous pregnancy. If, according to ultrasound data, fetal cardiac activity is not recorded, it is recommended to take fetal tissues for karyotyping.

Once fetal heart activity is detected, additional blood tests are no longer needed. However, in later pregnancy, an assessment of the level of α-fetoprotein is desirable in addition to ultrasound. An increase in its level may indicate malformations of the neural tube, and low values ​​- chromosomal disorders. An increase in the concentration of α-fetoprotein without obvious reasons at a period of 16-18 weeks of pregnancy may indicate the risk of spontaneous abortion in the second and third trimesters.

Of great importance is the assessment of the fetal karyotype. This study should be carried out not only for all pregnant women over 35 years old, but also for women with recurrent miscarriage, which is associated with an increased likelihood of fetal malformations in subsequent pregnancies.

When treating recurrent miscarriage of an unclear cause, one of the alternatives can be considered the IVF technique. This method allows you to perform a study of germ cells for the presence of chromosomal abnormalities even before artificial insemination in vitro. The combination of the application of this technique with the use of a donor egg gives positive results in the onset of the desired full-fledged pregnancy. According to statistics, a full-fledged pregnancy in women with recurrent miscarriage after this procedure occurred in 86% of cases, and the frequency of miscarriages is reduced to 11%.

In addition to the various methods described for the treatment of recurrent miscarriage, it should be noted that non-specific, background therapy, the purpose of which is to relieve the increased tone of the muscular wall of the uterus. It is the increased tone of the uterus of a different nature that is the main cause of premature miscarriages. Treatment involves the use of no-shpa, suppositories with papaverine or belladonna (introduced into the rectum), intravenous drip of magnesia.