Lectures on miscarriage

2021-03-22 12:00 AM

The rate of miscarriage is really difficult to assess, as many miscarriages occur before a woman realizes she is pregnant.

Define

Miscarriage is called when the fetus is expelled from the uterus, termination of pregnancy before gestational age can be independently viable outside the uterus (even with medical intervention). According to the World Health Organization (WHO): Miscarriage is when a fetus is expelled from the uterus before 22 weeks of pregnancy or weighing less than 500 grams. Early miscarriage is a miscarriage before 12 weeks and a late miscarriage is 12-20 weeks.

Classification

Miscarriage is divided into 2 categories:

Spontaneous miscarriages are types of miscarriages that suddenly happen in a normal pregnancy.

Recurrent miscarriage: when spontaneous abortion is 3 or more times in a row. According to Malpas, a woman with a history of three consecutive miscarriages has a 50% chance of having a live baby and a 20% higher risk of preterm birth than the average person.

Frequency

The rate of miscarriage is really difficult to assess because many miscarriages occur before a woman realizes she is pregnant. This percentage is estimated from 22-75%.

Among the cases of realizing that they are pregnant, the rate of miscarriage accounts for about 12%, and half of these occur before 8 weeks of gestation.

80% of miscarriages occur in the first 3 months and 20% occur in the second trimester.

How to miscarriage according to gestational age

First 2-month miscarriage (less than 8 weeks): Most miscarriages before 8 weeks are complete miscarriages. In this period, the egg is just a wrap of bird eggs, inside with embryos, on the outside with placental spikes. If it occurs, usually occurs once, it is covered with blood. The skin is very thin, will come out in the following days. Therefore, this period is less likely to remain placenta, hemorrhage.

Third- and fourth-month miscarriage (8-16 weeks): The implantation is more solid, and better nourished, the rate of miscarriage decreases. In this age, incomplete miscarriage is common. During this period, the egg has grown into a fetus, if the miscarriage often miscarries, the head: the fetus, then two: placenta out, then three: the output. So easy to miss placenta and often heavy bleeding.

Fifth- and sixth-month miscarriages: Miscarriage takes place like childbirth: the reincarnation occurs, then the placenta and the placental membranes come out.

The cause of miscarriage 

Diagnosing the cause of a miscarriage is important, but often difficult. For cases of 2 consecutive premature miscarriages or one late miscarriage, careful investigation of the history, the history of the disease, the general examination, and genitals, if necessary, combined with a hematology test. , biochemistry, cytology, and oocyte, sometimes it is necessary to have a scan of the uterus outside of pregnancy to find the cause.

About half of all miscarriages have a known cause.

General reasons

Heart disease, kidney disease.

Mother has diabetes.

Syphilis can cause miscarriages in the 4th and 5th months (syphilis bacteria pass through the placenta after 5 months, so it often causes preterm birth rather than miscarriage).

Weakness, lack of vitamins (especially Vitamine E).

Inflammation of the lining of the uterus (Toxoplasmoses, Listerioses).

Immunological etiology: fetus as a graft in the mother's uterus, the mother's T-lymphocyte-mediated abortion reaction against fetal antigens inhibits embryonic development due to HLA systemic mismatch (Humane Lymphocyte Antigens).

Environmental factors: smoking, drinking alcohol, radiation, toxins ...

Chromosomal disorders: If the culture of the abortion sacs is cultured to make the chromosomes, about 50-85% of the miscarriages are caused by chromosomal disorders. However, according to Mishell et al., 80-90% of pregnancies miscarriage in mothers with chromosomal normal 3 or more miscarriages. Common disorders are in pairs of chromosomes usually number 6, 12, 13, 16, 17, 18, 21, or in the sex chromosome (XO in Turner syndrome) or haploid, triploid, mosaic pattern. Trichromosomal trisomy is most common (50-65%), followed by monomer 45XO (7-15%), triploid (15%), tetraploid (10%), and structural anomalies. bamboo (5%). 

The cause of a natural miscarriage

Acute bacterial infection: infection that kills the fetus or because of a high temperature that causes uterine contractions and miscarriage. Common causes are Rubéon, influenza, Toxoplasma infection, malaria, pneumonia, typhoid...

Trauma: strong, sudden, or multiple minor trauma in a row can cause a miscarriage. These traumata can be natural emotions caused by fear, extreme emotion, or physical trauma such as abdominal trauma or surgery.

Poisoning: Hazardous occupations that are not carefully protected can also cause miscarriages.

Unusual nesting eggs:

Nesting in the corner or at the waist is prone to miscarriage.

Twins, multiple pregnancies, multiple amniotic fluids.

Full or partial pregnancy pregnancies, so all spontaneous abortion specimens must be tested for pathology.

Causes of consecutive miscarriages

This is called recurrent miscarriage when a woman has 3 or more consecutive spontaneous miscarriages. Often due to many different reasons:

Causes of the uterus: Congenital or acquired uterine abnormalities:

The uterus is underdeveloped, the uterus is small, the cervix is ​​small and long.

Enlarged uterine fibroids or multiple nuclei.

Malformations in the uterus such as the twin uterus, the biconcave, and the uterine septum.

Uterine cleft: usually due to cervical tear damage after childbirth, curettage, cervical apex, or cervical amputation. The disease often causes sudden miscarriage in the middle 3 months of pregnancy, clinically happens very suddenly, without warning signs, the cervix is ​​open but the woman does not feel pain, labor occurs very quickly after a few attacks. Strong contraction and rupture of membranes. Post-miscarriages tend to occur earlier with a smaller fetal weight. Outside of pregnancy, the uterine cleft is diagnosed with certainty when the passage of Hegar No. 9 candle through the cervix is ​​easy.

Endocrine causes: all endocrine disorders can cause miscarriages, for example:

Decreases placenta gonadotropic hormones (hCG) and sex hormones (estrogen, progesteron).

Hyper androgenic hyperthyroidism, hyperthyroidism, or hypothyroidism can also cause miscarriage.

Rh factor incompatibility between fetus and mother.

Clinical

Threatened miscarriage

The embryo is still alive and has not been removed from the uterine lining.

Function:

Vaginal bleeding is the main symptom. Red or black blood, a small amount, can last for many days, the blood is often mixed with mucus. It is an alarming sign of an unusual pregnancy.

Women with a feeling of tightness, pressure in the lower abdomen, or back pain.

Entity:

An external examination is of little value because the uterus and fetus are still small, making it difficult to detect symptoms.

A speculum is always necessary to detect bleeding from the uterus and rule out bleeding from lesions in the cervix or vagina.

Vaginal examination: The cervix is ​​long, closed, the body of the uterus is soft and large, corresponding to gestational age.

Supersonic: 

It is very necessary to evaluate the cause of bleeding.

There is the phenomenon of dissection of a small part of a placenta or placenta membrane, the amniotic sac is even and clear, echoes of the embryo, fetal heart or not.

Miscarriage is difficult to avoid

Bleeding: heavy bleeding, bright red, may not bleed much but last for more than 10 days.

Abdominal pain: Pain in the hypotonic region, pain in each pain increasing.

Vaginal examination: the cervix has a phenomenon of erasure, the finger may be partially opened, the enlarged lower part due to the falling down of the cervix, making the cervix have a spinning top.

Are having a miscarriage

Vaginal bleeding a lot, fresh, with blood clots.

Severe pain in the hypotenic region due to the strong contraction of the uterus to expel the fetus.

Examination found that the lower uterus was enlarged due to the abortion of the uterus from the uterine wall. The cervix is ​​open, sometimes the placenta can be seen appearing in the cervix.

Placental miscarriage

Often patients have had symptoms of miscarriage before, then have at once more abdominal pain, more bleeding. The patient may notice an expulsion of a piece of tissue from the vagina. However, the bleeding continued and still dulled abdominal pain.

Examination of the cervix is ​​still slightly open or closed. The uterine body is even larger than normal.

The patient may present with an infection.

Ultrasound can reveal the placenta in the uterus.

Bleeding miscarriage

Vaginal bleeding a lot, fresh blood. Patients may present with blood loss dizziness.

A vaginal examination found a lot of fresh blood mixed with blood clots. Often there is a fetus sticking up in the cervix or in the vagina. In case the patient is late in hospital, the fetus has miscarried, these symptoms will not be present, but bleeding symptoms are prominent.

Infection miscarriage  

Women with prolonged vaginal bleeding accompanied by infectious syndrome: fever, rapid pulse, infected facial expression, increased white blood cells, increased CRP.

Vaginal examination revealed an open cervix, dark, foul vaginal blood. The uterus is soft, the pressure is painful.

Implementing the quadrants

It is necessary to fully exploit the clinical and subclinical symptoms to diagnose the clinical forms of miscarriage.

Differential diagnosis

Pseudo-abortion of ectopic pregnancy:

In an ectopic pregnancy, there is also vaginal bleeding and monolithic removal of the ectopic part of the uterus, so it is easy to confuse with miscarriage.

Examination of signs of ectopic pregnancy such as delayed period, bleeding, uterus soft, painful pressure, and Douglas pockets full and painful. The uterus is not large enough to match the gestational age, can feel the tumor next to the uterus pain. If the uterine is curled, the anatomical image of the curettage will be the uterine lining with the loss of the uterine reaction, and there are no spikes in the mass. Ultrasound: no pregnancy sac in the uterus, thick uterine lining, no images of placental tissue plaques, bhCG test to confirm the diagnosis.

Pregnant eggs:

Often prolonged blood weed, causing anemia, vomiting a lot.

Hysteroscopy is usually older than gestational age, two glandular cysts can be palpated. The fetal parts cannot be touched, the fetal heart cannot be heard.

Quantitative bhCG in blood per 100,000 mUI / ml.

Ultrasound: pictures of falling snow.

Adnexitis:

If acute, there is an acute septic syndrome and often pain on both sides of the pelvic fossa.

Appendicitis:

There is an infectious syndrome and digestive disorders, the pain is localized in the right pelvic fossa.

Treatment 

Threatened miscarriage

Absolutely rest, anti-constipation snacks.

Vitamin supplements, especially Vitamin E, can use folic acid 300 mg/day and Vitamin B6.

Anticonvulsants.

Endocrine treatment:

Natural progesterone to reduce uterine contractility is main, should not use synthetic progesterone because it can cause birth defects, especially during embryogenesis in the first two months of pregnancy. Some authors appoint progesterone alone, others in combination with estrogen due to the increased nutritional effect on the uterus. Utrogestan 100 mg, dose depending on the case, up to 400 mg/day.

Pregnyl: 10,000 UI at diagnosis of pregnancy, then 5,000 UI 2 times a week until 12 weeks.

Endocrine treatment should not be used in pregnancy for more than 14 weeks.

Use antibiotics when the infection is suspected.

Avoid having sex until 2 weeks after the bleeding stops.

Miscarriage or still miscarriage

The principle is to curl the uterus to remove the fetus and placenta, to prevent bleeding and infection. During management, it must be based on the patient's systemic condition, gestational age, cervical erection, and cervical opening for appropriate management.

Bleeding miscarriage:

Commune level: referral to the higher level, if there is a shock to transmit isotonic saline infusion of 9o / oo while transferring or waiting for the higher level to deal with it.

District level: active resuscitation by infusion and blood. When the systemic condition allows, then dilate the cervix, remove the fetus, suck or curl the uterus. After intramuscular curettage 10 units oxytocin. Oxytocin can be given several times if the bleeding persists. Rectal misoprostol can also be used to help control bleeding.

New miscarriage without bleeding:

Commune level: Give antibiotics to drink, counsel, and refer to district referral.

District level: Ultrasound of the uterus, if it is clean, no need to suck or curl. If there is any leftover placenta, remove all of the placenta.

Infection miscarriage:

Antibiotic treatment, consultation, referral.

For a combination of high-dose antibiotics and oxytocin.

Ovarian curettage after at least 12 - 24 hours. Be careful when curettage because it is prone to perforation of the uterus and spread of infection.   

In severe infections (generalized metritis, septicemia), hysterectomy may be indicated. Need advice before and after surgery.

Recurrent miscarriages:

To determine the cause, it is necessary to use exploration and testing methods such as hormone quantification, syphilis test, Rh factor, chromosome, uterine scan ...

Removal of uterine fibroids, uterine septum surgery ...

Stitch the cervix for cases of the open uterine waist.

Treatment of systemic causes: syphilis, diabetes mellitus, nephritis.

Treatment of endocrine disorders such as hypothyroidism; With estrogen deficiency, progesterone should be treated immediately and early from the new pregnancy and continuously during the first 12 weeks of pregnancy ...