Only ultrasound can confirm the diagnosis of "non-developing pregnancy", but errors also occur. Non-developing pregnancy: causes and signs Pregnancy does not develop causes

Almost 70-80% of pregnancies end unfavorably in the range of 1 to 3 obstetric months, most of which were doomed due to chromosomal and genetic abnormalities. The shorter the gestation time, the higher the probability of interruption precisely because of natural selection, when an embryo with gross developmental anomalies - often incompatible with life - freezes or is rejected by the mother's body. Fetal loss due to genetic damage is possible in the life of any couple and is considered accidental, however, if the situation repeats, spouses are advised to undergo karyotyping.

Also in the 1st trimester, the aggressiveness of the mother's immunity to the fetal egg leads to the loss of the fetus, hormonal disbalance or lack of nutrients. These causes are less common, but only hormonal imbalance can be corrected at the stage when there is a threat of miscarriage, and the embryo is still alive (there is no severe developmental delay and / or there is a heartbeat).

Early termination symptoms include:

• bloody issues;
• drawing pains in the lower abdomen.

The first signs of a miscarriage in the 1st trimester

The term "miscarriage" is ambiguous, and is differentiated into several concepts, depending on which further tactics are determined.

A threat of miscarriage or interruption is considered to be light spotting and minor pain in the lower abdomen, provided that otherwise there is no strong lag in the size of the chorion, KTR in development. In this case, observation in a hospital is prescribed to support the pregnancy. In all other situations, this tactic is not used.

The characteristic features of the miscarriage process itself are the significant rejection of the fetal egg from the uterine wall and the opening of the cervical canal. Bloody discharge or clots are observed, the pain may be constant or paroxysmal. Further saving is not possible. Subsequently, only two things matter. The first is whether the process of spontaneous abortion is completely completed or whether particles remain that must be removed surgically; the second - the fetus was alive or dead for further search for the cause of the interruption.

Miscarriage and non-developing - are they always the same?

In medical practice, it is generally accepted that a missed abortion is a failed spontaneous abortion, when the process of elimination and rejection of the dead fetus is delayed or does not occur at all. This is reasonable, however, from the point of view of differentiation and the search for the reason why further gravid development is impossible, it is necessary to distinguish whether an undeveloped or live fetus is aborted.

classic miscarriage

Classical spontaneous abortion usually refers to the rejection of a still-living fetus. In practice, such an outcome in the early stages practically does not occur, but if it does, then more often such an abortion is justified by the inconsistency of the woman's hormonal background or by a violation in the chain between the embryo and the mother's body. Further tactics - for maintaining the next gravid period - is suggested on the basis of a detailed examination:

• clarification of the genetic set of abortus:

1. If there is no breakdown, then you can proceed to search for the cause elsewhere.
2. An anomaly was found, but it is random. The search for the culprit of what happened can be completed.
3. An anomaly is detected, but not random or the interruption is not the first time. In this case, karyotyping of the parents is necessary;

• assessment of the hormonal status of a woman. Violations are corrected before the onset of the next gravid period, and treatment is signed for the entire first trimester. Progesterone preparations, antiandrogens, thyroid hormones, or glucocorticosteroids may be used;
• determination of immune activity (in some cases, examination for genetic thrombophilia). This examination - antibodies to hCG, antiphospholipid screening, lupus anticoagulant - is recommended only for recurrent miscarriage. This kind of examination is never carried out without excluding other reasons, as well as with a single loss of the fetus, especially in the 1st trimester.

Anembryony

Sometimes there is the development of a fetal egg in the absence of an embryo and / or a yolk sac in it. Often, such a pathology is accidentally detected only at the first screening, since the growth of hCG may not differ significantly from normal dynamics.

If the anembryony is true - the PY was empty from the very beginning - then a genetic problem can be assumed, most often of a sporadic nature. If anembryony proceeds according to the principle of regression (sometimes the embryo is determined in the first weeks, but it is no longer present at the screening), then the tactics are similar to the situation of a non-developing pregnancy.

frozen

A non-developing pregnancy can be suspected by similar signs of a threatened abortion. Most often, such symptoms appear when a non-viable organism is in the womb for more than 2-4 weeks and it is associated with a decrease in placental hormones, which are no longer stimulated by the deceased fetus.

But most often, when fading in the first trimeter, there are no signs - a woman may not suspect anything, often she continues to feel pregnant without a threat of interruption. Of course, a decrease in the sensitivity of the mammary glands, a decrease in the size and swelling of the breast, the disappearance of signs of toxicosis is possible, but these features are very subjective and do not always reflect the actual situation. Symptoms may disappear and reappear; it may be absent altogether from the very beginning of gestation; the body is able to have time to adapt to changes - all this is not excluded in the physiological course.

The only reliable criterion for a non-developing pregnancy can be considered an ultrasound transvaginal examination, in which, in the period of more than 1 obstetric month of gestation, the heart rate should be determined, and the growth dynamics of the fetal egg and embryo should also be noted. Another auxiliary laboratory method can be considered the determination of the growth dynamics of hCG in the blood, however, this method will not be relevant for 7-8 gestational weeks, since in this period the growth of hCG can not only begin to slow down, but even stop completely (for example, from about 10 -12 weeks there is a gradual decrease in the level of the hormone).

What to do?

With an actual spontaneous abortion - classic or failed - the tactics are always the same. It is necessary to completely remove the fetal tissues from the uterine cavity. The methods are varied and depend on the duration of amenorrhea, the presence of retrochorial hematoma. The doctor chooses between instrumental extraction with a curette, vacuum aspiration or medical stimulation. The best outcome is considered a spontaneous complete abortion, in which no foreign particles remain in the uterus without outside intervention. But this is extremely rare.

Such a failure won't happen again

No one is immune from the loss of a child. Often this happens against the background of absolute health without any prerequisites, why it happened and who is to blame - you can never know. In civilized countries, after 1-2 interruptions, a complete examination is not prescribed, since it is believed that miscarriages were random. And this is true - in the vast majority it is a cruel kind of natural selection.

But with losses over three, an in-depth study of the problem is necessary. An approximate list for finding the cause of habitual miscarriage of the first trimester is as follows:

• genetic expertise;
• determination of the sensitivity of uterine receptors to progesterone and estrogen (laboratory, ultrasound, pipel biopsy);
• the level of homocysteine ​​to clarify the dosage of folic acid;
• examination for APS and congenital thrombophilia (coagulogram is not the analysis by which these pathologies are determined).

Most medical centers also recommend a hormonal assessment and a thorough search for chronic infections. However, hormonal imbalance is ruled out with losses over 7 weeks, and infections respond well to treatment and do not lead to recurrent miscarriage. DNA fragmentation of spermatozoa and, in general, a detailed examination of the spermogram are not recommended in couples with losses, when a heartbeat has already been recorded at least once on ultrasound.

The loss of a child, albeit at an early stage, when you are just starting to get used to your new status and position, always big stress for every woman. However, do not despair, look for the guilty and give up. Modern medicine provides many opportunities for solving such problems, which increases the chances of having a long-awaited child.

This topic is very exciting and delicate. Talking about it is always difficult and joyless. But it is also impossible to remain silent, because an undeveloped pregnancy, unfortunately, is not so rare today.

If the fetus froze at a time when a rather large tummy was already visible, then it may slightly decrease in size. At a later date, the fading will be indicated by the absence of movements for an extended period of time.

Whenever misfortune occurs, a woman can feel very bad for no apparent reason, as it seems to her.

The described signs of a non-developing pregnancy can appear individually or in combination, several at once, or completely absent - in each individual case, everything happens differently.

We sincerely hope that this information will forever remain theoretical and unclaimed for you. But if, God forbid, it happened otherwise, then do not be discouraged: 80-90% of women safely bear the next pregnancy. Moreover, the chances of success increase if the pregnancy is planned in advance, passed and properly prepared for motherhood (and fatherhood too).

Specially for- Elena Kichak

How beautiful pregnant women are! But sometimes an inexorable fate brings down terrible and unbearable trials on their shoulders.

One of them is non-developing pregnancy, the death of the unborn baby.

This can happen at any stage of pregnancy. This pathology occurs in 10-20% of cases.

Crisis periods are identified when the fetus is most vulnerable to negative impacts:

• 7-12 days of development (implantation period);
• 3- development (the period of embryogenesis);
• the first (formation of the placenta);
• 20- development (formation of the most important functions in the body of the fetus).

The most dangerous are the first days and weeks of baby development. In the early stages of its development, the fetus is most sensitive to damaging, destructive factors.

What should alert a pregnant woman?

Diagnosis of the disease

Signs and symptoms

In most cases, a stop in the development of a child is not felt by pregnant women and is not accompanied by pronounced symptoms.

In the early stages:

• disappearance;
• increase in appetite;
• reduction of pain in the mammary glands.

At a later date:

• the appearance of bleeding;
• increase in body temperature;
• drawing pains in the lower back.

Such signals can accompany the normal course of pregnancy. Only a specialist can finally confirm the death of the embryo through ultrasound and research. Who is to blame for failed motherhood?

Causes

As a rule, a frozen pregnancy is the result of a combination of unfortunate circumstances and factors.

The reasons can be divided into several groups.

Genetics. Sometimes, during the formation of an embryo, various changes occur in the chromosomes, genetic disorders (a larger or smaller set of chromosomes).

The reason for this may be hereditary predisposition, the use of drugs, alcohol, living in environmentally unsafe areas.

Genetic disorders are the most important causes of this pathology (up to 70% of all cases). "Wrong" genes can come from both parents.

Infections. Infectious diseases of the expectant mother is the second most common cause of non-developing pregnancy:

• viral -, enterovirus;
• bacterial - mycoplasmas, streptococci, gonococci, chlamydia, ureaplasmosis.

As a result of the presence of any infection in a pregnant woman, acquired or chronic, infection of the fetal egg occurs.

Infection can occur in three ways:

1. In the inflammatory process of the uterine mucosa and its appendages(endometritis, salpingoophoritis) microbes penetrate the fetal egg. In this case, the woman’s uterus itself is not ready to bear a child, the fetal egg is not attached tightly enough, and its rejection follows.
2. With inflammatory processes in the vagina itself(fungi,) bacteria penetrate to the fetal egg through the cervix. Infection of the embryo and amniotic fluid occurs, which is fraught with rupture of the fetal bladder itself.
3. With past viral infections(, ORZ,) microbes penetrate to the fetal egg with blood flow through the placenta. Significantly reduced oxygen supply nutrients future baby

When infected, the fetus stops its development, the child dies.

Do not forget that pregnancy is accompanied by a strong suppression of the entire immune system. An exacerbation of all latent infectious diseases in a woman may begin.

Therefore, it is very important to treat all latent infections in time before planning motherhood and do everything possible so as not to catch a cold while pregnant.

Immunology. Sometimes a woman may have various predisposing factors that can cause the death of the embryo. This is the appearance of protective antibodies to the hormone produced by the fetal egg (antiphospholipid syndrome), incompatibility at the immune level of the father and mother.

Immunological incompatibility can be expressed by increased thrombus formation. In all cases, the nutrition of the embryo is disturbed, its development stops and the fetus dies.

Endocrinology. The pathological state of the endocrine system of a pregnant woman can provoke the death of the fetus. There can be many reasons for the disruption of the proper functioning of the endocrine system and hormonal disorders.

The most common of them are:

• an increased amount of sex hormones according to the male type (hyperandrogenism). In 20% of cases during pregnancy, there is a sharp jump in the level of male hormones.
• an increased amount of a hormone that stimulates milk production (hyperprolactinemia).
• violation of the proper development of the ovaries (), which affects the menstrual cycle and the production of female sex hormones.
• improper functioning of the thyroid gland (dystrophy, obesity).
• underdevelopment of the female reproductive organs (infantilism).

In case of violations of the endocrine system the body produces insufficient amounts of a hormone that is responsible for preparing the entire female body for pregnancy. An embryo that is weakly attached to the uterus receives insufficient nutrients and dies.

Women are at risk who lead an incorrect lifestyle that is harmful to the state of pregnancy. Constant stress, overstrain, long depression. Work in unsuitable conditions (high humidity, constant stuffiness).

All this can lead to the appearance and detachment of the placenta, which disrupts the supply of oxygen and nutrients to the fetus and, as a result, the death of the unborn baby.

Multiple abortions, transferred . Woman's age(in case of the first one), peculiarities anatomical structure uterus(saddle-shaped,) - all this refers to the provoking factors for the appearance of pathology during pregnancy.

According to the observations of experts, a pregnancy, compared to a natural one, is more likely to turn into a dead one and end in the death of the embryo.

What awaits a woman who has had one or more unsuccessful pregnancies, what do doctors say about this?

Consequences of non-developing pregnancy

As a rule, the vast majority of women have every chance to conceive a child again and bear it safely.

According to statistics, this is 80-90% of all women who have experienced a missed pregnancy.

If the conception ended in the death of the fetus in two or more cases of pregnancy, then the non-developing pregnancy goes into the category of "habitual".

In this case, in order to safely endure the baby, a thorough examination of both spouses is required.

Pregnancy after an illness

Planning for the next pregnancy resolved six months after the failure.

This break is aimed at the complete restoration of the hormonal status, reproductive functions of the body and includes the following mandatory examinations:

• Ultrasound of the pelvic organs;
• PCR diagnostics (detection of urogenital infections);
• blood test for the level of autoantibodies,;
• blood test to detect antibody titer to;
• determination of the level of thyroid hormones in the blood.

This list can have many more items. An individual examination plan is applied to each woman, which is prescribed by a gynecologist.

But how is an undeveloped pregnancy treated, what do doctors do in this case?

Treatment of non-developing pregnancy

If a frozen fetus is found in a pregnant woman, doctors develop tactics for taking measures for delivery, based on each specific case.

Spontaneous. Shortly after the death of the embryo, the level of placental hormones in a woman decreases sharply, which leads to an independent miscarriage.

With the help of medicines. In early miscarriages (before 8 weeks), doctors may use the mifepristone (progesterone) antagonist drug in combination with misoprostol (an analogue of prostaglandin E1). After these two drugs enter the body, the embryo is rejected, it is miscarried.

Operational treatment. This method is carried out in a hospital setting. Assign curettage (curettage of the uterine cavity) on an individual basis. The operation is similar to an abortion, it takes place under general or local anesthesia.

Not a single woman is immune from this misfortune. Non-developing pregnancy It's not a disease, it's not a diagnosis, it's not a sentence. This is a warning that motherhood must be carefully and competently planned.

It consists in the fact that a woman is not bothered by anything for some time after intrauterine death of the fetus. She enjoys her position, sometimes unaware that the child does not develop and dies, especially in the first and early second trimester, when the expectant mother does not yet feel the fetal movement. Unfortunately, this can happen to every woman.

information Symptoms of non-developing pregnancy are slightly different (up to 12 weeks) and (after 12 weeks) terms, but they are all divided into probabilistic and reliable. The first category includes those symptoms that may prompt the doctor or the woman herself to a more detailed examination, but are not the main ones for determining a miscarriage. Reliable signs are those on the basis of which a diagnosis is made.

Symptoms of a missed pregnancy in the early stages

Probable early symptoms

• The very first signs of a missed pregnancy in the early stages are a decrease in the subjective sensations of a woman that appear with the onset of conception: manifestations (nausea, vomiting), breast engorgement, sensitivity to odors, a change in taste preferences.
• Decrease. Basal temperature (body temperature at rest, which is measured in the rectum in the morning at the same time, without getting out of bed) increases in the second phase of the menstrual cycle by 0.3-0.5 degrees and remains elevated during conception and pregnancy. This is facilitated by a high level of the hormone progesterone, which preserves pregnancy. If there is a fetal freeze, basal body temperature drops to normal (36.4-36.8 degrees Celsius). However, this can also occur with a lack of the hormone progesterone, and with a threatened miscarriage.
• Gynecological examination. During a gynecological examination, the doctor assesses the size, consistency of the uterus, the length and density of the cervix, the patency of the cervical canal (cervical canal). A sign of a missed pregnancy is the smaller size of the uterus compared to what they should be at a given estimated period. If the doctor finds such a discrepancy, it is necessary to do an ultrasound of the uterus to confirm or refute the suspicions.
• Bloody discharge from the genital tract. Usually, the appearance of bloody discharge indicates a spontaneous miscarriage that has begun. Most often, this symptom joins some time (2-4 weeks) after the intrauterine death of the baby.
• Pulling pain in the lower abdomen, an increase, also join after some time after the fetus fades.

Reliable signs of non-developing pregnancy

1. You can determine a frozen pregnancy in the early stages with the help of human chorionic gonadotropin (hCG). HCG is produced by cells surrounding the embryo, starting from the 7th day after fertilization. Every day, the level of this hormone almost doubles and reaches a maximum by the 10th week of pregnancy, then gradually decreases and remains at the same level until the very birth. In the very early stages, when the fetal heartbeat is not yet determined by ultrasound, fetal fading can be suspected by the level of hCG, since each period of pregnancy is characterized by a certain level of hCG, as well as its daily growth up to 10 weeks. If chorionic gonadotropin is lower than the values ​​characteristic of a given week of pregnancy, and when the analysis is repeated the next day, its level drops, this gives the right to diagnose fetal fading.
2. One of the reliable signs of a missed pregnancy is the absence of a fetal heartbeat on ultrasound. The baby's heartbeat begins to be determined from the 5-6th week of pregnancy. Therefore, if the fetus is visualized well, but there is no cardiac activity, this means that the fetus has frozen. But if the heartbeat is not detected at the earliest possible date, and only a fetal egg is visible, you must wait and do a second ultrasound in 5-7 days. During this period, the size of the fetal egg during normal pregnancy increases.

The criteria for violation are:

• The absence of a heartbeat with a coccygeal-parietal size of the fetus more than 5 mm;
• The absence of an embryo with a fetal egg size of more than 25 mm;
• Abnormal yolk sac.

Signs of a missed pregnancy in the later stages

additionally In addition to those listed, from the middle of the second trimester, another sign of a missed pregnancy joins - the woman stops feeling the baby move. Usually she begins to feel it from 18-20 weeks (it matters whether this is a second pregnancy or not, the complexion of the woman herself).

At first, the movements are not so obvious and active, more like the work of the intestines. Sometimes the movement of the child throughout the day is not so active. A woman is busy with her daily activities, especially if she is still working, she is constantly on the move, so the slightest movements of the child may go unnoticed. And when, in the evening, the expectant mother can finally relax, lie down on the sofa or bed, the child's activity intensifies (at least it feels like that) and the mother can concentrate and enjoy the pushes of her baby. Pay attention to your child's activity throughout the day. If he hasn't pushed you for a long time, sit down, rest, talk to him to feel his presence. If you haven't moved in 6 hours, that's cause for concern!

If, nevertheless, you have been diagnosed with a non-developing pregnancy, do not despair. Treat this as an occasion to prepare more carefully for a subsequent pregnancy.

Reliable signs in the later stages

A reliable sign of intrauterine fetal death is the absence of a heartbeat on ultrasound.

Non-developing pregnancy is a complex of pathological symptoms, including intrauterine death of the fetus (embryo), pathological inertia of the myometrium and disturbances in the hemostasis system.

SYNONYMS

Frozen pregnancy, missed miscarriage, missed abortion.

ICD-10 CODE
O02.1 Missed miscarriage.

EPIDEMIOLOGY

The frequency of miscarriage in the population is 20%. In the structure of miscarriage, the frequency of habitual miscarriage ranges from 5% to 20%, and non-developing pregnancy - 45–88.6% of the number of spontaneous miscarriages in the early stages

PREVENTION OF MISSED PREGNANCY

Prevention consists in correcting violations of the body's immunoreactivity according to the ELIP-Test, restoring the eubiosis of the vaginal microflora.

In the hyporeactive state of the body, the treatment of chronic inflammation is carried out according to traditional schemes: an increase in immunoreactivity (prodigiosan), the appointment of immunomodulators and interferon inducers.

In a hyperreactive state, immunomodulators and plasmapheresis are prescribed.

In order to normalize the hypothalamic-pituitary-ovarian system, to restore hormonal reception of the damaged endometrium, it is advisable to conduct hormone-correcting therapy. Recommend the appointment of microdoses of combined oral contraceptives from the first day of termination of pregnancy for 6 months.

CLASSIFICATION

According to the results of ultrasound, two types of non-developing pregnancy are distinguished: anembryony (Fig. 24-1) and death of the embryo (fetus) (Fig. 24-2).

Echographically distinguish anembryony I and II types. In type I anembryonia, the embryo is not visualized, the average diameter of the fetal egg does not exceed 2.0–2.5 cm, the size of the uterus corresponds to the 5–7th week of pregnancy. Of decisive diagnostic importance is the lag in the size of the uterus and the fetal egg from the gestational age, the cessation of their growth during dynamic observation.

Rice. 24-1. Non-developing pregnancy of the type of anembryony.

Rice. 24-2. Non-developing pregnancy according to the type of embryo death.

In type II anembryonia, despite the absence of an embryo or the visualization of its remains (usually in the form of a vertebral fold), the fetal egg grows at a normal rate. By the 10–11th week of pregnancy, the diameter of the fetal egg reaches 4.5–5.5 cm. In type II anembryony, the laying of the villous chorion is not clearly detected, which is normally determined already from the 8th week of pregnancy.

ETIOLOGY (CAUSES) OF MISSED PREGNANCY

Non-developing pregnancy is a polyetiological complication of pregnancy, the most common cause is chronic endometritis with the persistence of opportunistic microorganisms and / or viruses. It is known that during primary infection in early pregnancy, damage to the embryo is possible, incompatible with life, leading to sporadic spontaneous miscarriage. In most women with missed pregnancy and chronic endometritis, two or three or more types of obligate anaerobic microorganisms and viruses prevail in the endometrium. But there are other factors that contribute to non-developing pregnancy:

anatomical anomalies;

Chromosomal defects

disorders of the blood coagulation system.

Currently, genetic, immune, thrombophilic factors, which are the least studied, are of the greatest interest. Thrombophilic factors are genetically determined.

The fetal egg with the mother's body is a functionally unified hormonal system. The ability of the fetus to take an active part in the synthesis and metabolism of progesterone has been proven. With threatening miscarriage, these processes are violated. Progesterone deficiency leads to the pathology of decidualization of the endometrial stroma, weak invasion of the cytotrophoblast and, as a result, to a decrease in uteroplacental circulation. With miscarriage by the type of missed pregnancy, the fetal metabolism of progesterone stops - an important hallmark miscarriage from spontaneous abortion.

Genetic factors include chromosomal abnormalities of the embryo or fetus, formed by the fusion of two parental cells with the presence of point mutations in the chromosome set. When examining the material of miscarriages, most of the detected chromosomal disorders- quantitative (95%).

The shorter the gestational age at the time of the death of the fetal egg, the higher the frequency of chromosomal aberrations. In the presence of chromosomal aberrations, embryogenesis is impossible or is sharply disturbed in the early stages. Assume the relationship of developmental disorders in chromosomal aberrations with a reduced ability of cells to divide. In this case, there is a sharp desynchronization of the processes of development of the embryo, development of the placenta, induction of cell differentiation and migration.

Causes of quantitative chromosomal aberrations.

Failures of meiotic division: cases of non-disjunction of paired chromosomes, this leads to the appearance of monosomy or trisomy. Chromosome nondisjunction in eggs and spermatozoa can occur at any time during meiotic division.

· Failures that occur during fertilization: cases of fertilization of the egg by two spermatozoa (dyspermia), resulting in a triploid embryo.

· Malfunctions that occur during the first mitotic divisions: The complete tetraploidy that occurs during the first division of mitosis leads to chromosome doubling and the absence of division of the cytoplasm. Mosaics arise in the case of such failures at the stage of subsequent divisions.

PATHOGENESIS

The leading place in the etiology of miscarriage is occupied by a persistent viral-bacterial infection. The pathogenesis of the development of missed pregnancy is chronic endometritis. For acute or chronic viral infection local and general immunity is activated in the body. Increased synthesis of damaging cytokines, reduced synthesis of growth factors contributes to abnormal invasion and damage to the trophoblast in early pregnancy. Some viruses, such as human papillomavirus (HPV), CMV, infect the trophoblast and vascular endothelium, causing an increase in the production of prothrombinase, contributing to the further destruction of the endothelium. At the same time, protective mechanisms that contribute to the preservation of pregnancy are violated: the expression of HLA-- by trophoblastomas decreases, the secretion of growth factors decreases, and the activation of the TH-2 pathway of lymphocyte differentiation does not occur. The study of the species and quantitative composition of the microcenosis of the vagina and cervical canal revealed the relationship between the dysbiotic state of these microecosystems and persistence conditionally pathogenic microorganisms in the endometrium. Viral diseases of the female genital organs, which develop against the background of immunodeficiency conditions, contribute to the development of complications in secondary immunodeficiencies. That is why the presence of a chronic viral infection is considered an important provoking factor in the development of chronic endometritis.

The main reason for the chronic course of the inflammatory process is considered to be the inadequacy of the ongoing antibacterial treatment due to changes in last years etiological structure of infectious morbidity.

The inflammatory process can develop as a result of the activation of the normal microflora of the vagina, for example, when general or local immunity is weakened.

An important role in the pathogenesis of missed pregnancy is assigned to the cytokine system. With excessive deposition of circulating immune complexes in tissues, immunopathological processes occur, accompanied by pronounced disturbances in the microcirculatory bed. In patients with non-developing pregnancy, there is a lack of activity of lymphocytes and an imbalance in the cytokines produced by them. A shift in the balance leads to an increase in the production of pro-inflammatory cytokines, excessively pronounced manifestations of the inflammatory process, even with the persistence of the infectious agent. This disrupts the interaction of cells, as a result - implantation becomes defective, the depth of penetration is insufficient or excessive.

The frequency of structural chromosomal aberrations in the material of miscarriages reaches 80%. Approximately half of the cases of these anomalies are inherited from parents, the other half of the cases arose de novo.

The integrin heterodimer a-V;b-3, which appears on the 20th day of the menstrual cycle and opens the “implantation window”, is of the greatest importance for the implantation process. The appearance of the a-V;b-3 heterodimer is due to the activation of growth factors HB-E-F (heparin-bindin- - rowth factor) and E-F (epidermal - rowth factor). The connection of the a-V;b-3 heterodimer with the osteopontin ligand indicates the beginning of the interaction between the embryo and the endometrium, i.e. start of invasion. Progesterone stimulates the synthesis of osteopontin and the production of endometrial calcitonin, which increases the intracellular content of calcium ions. Calcium potentiates the adhesion of the trophoblast to the endometrium by redistributing the protein molecules of the receptors and their ligands. With a frozen pregnancy, a violation of the structure of the endometrium occurs - the ratio of the components of the extracellular matrix (collagens of different types) changes.

The consequence of the Leiden mutation is a disruption in the functioning of the protein C system, which is the most important natural anticoagulant pathway: protein C, inactivating factor Va, does not affect it; activated factor V, connecting with factor Xa on the phospholipid surface, accelerates the reaction of thrombin formation by tens of thousands of times, this leads to the development of thrombophilia. With APS in the mother's body, antibodies (I-A, I-, I-M) are produced and circulate in the blood to the phospholipids of platelet cell membranes, resulting in an imbalance in the anticoagulant blood system.

The main manifestations of APS:
arterial and venous thrombosis;
miscarriage;
infertility.

Mechanisms of thrombophilia in APS:
Violation of the prostacyclin-thromboxane A2 ratio;
Changes in the content and activity of antithrombin III;
Expression of endothelial procoagulants (tissue factor, von Willebrand factor, platelet activating factor);
Violation of the activation of protein C and the development of resistance to it.

The retention of a non-developing fetal egg or a dead fetus in the uterus affects the maternal organism.

The absorption of the products of autolysis of the tissues of the fetal egg into the mother's bloodstream (due to the increased permeability of the membranes) violates the intravascular conditions of hemostasis. A long stay of a dead fetal egg in the uterus significantly reduces the hemocoagulation activity of tissue and vascular factors of the placenta, this is caused by degenerative changes in the placental tissue. Prolonged exposure of the autolysis products to the uterus reduces the contractility of the myometrium.

The inertia of the uterus in NB is explained by a violation in the "mother-placenta-fetus" system. The uterus is deprived of a universal inhibitor of the start of contractile activity and the elimination of pregnancy - the fetal endocrine factor.

Inhibition of the contractile function of the uterus in this pathology is associated with regressive changes in the functional bioenergetics of the myometrium due to the lack of hormonal reinforcement from the fetus. In the classic hormonal chain of labor induction, key fetal links - oxytocin, DHEAS, cortisol - fall out.

CLINICAL PICTURE (SYMPTOMS) OF FAILED PREGNANCY

The clinical picture of a failed miscarriage is characteristics. The subjective signs of pregnancy disappear in the patient, the mammary glands decrease in size and become soft. Menstruation does not return. In the expected period, no movement of the fetus is noted. However, if fetal movements appear, they stop.

When a dead fetus is retained in the uterus for more than 3–4 weeks, 10% of women report general malaise, weakness, dizziness, and fever. The disappearance of nausea, vomiting, salivation are characteristic subjective signs of the death of the fetal egg in the first 12 weeks of pregnancy. In the second half of pregnancy, a woman notes the cessation of fetal movement. The symptom of softening of the mammary glands occurs on the 3-6th day after the death of the fetus. Milk appears in the mammary glands instead of colostrum. Breast engorgement and the release of a significant amount of colostrum are observed in women with fetal death that occurs after 25 weeks of development.

Clinical signs of a missed pregnancy (pain, bloody discharge from the genital tract, lagging behind the size of the uterus from the expected gestational age) appear 2-6 weeks after the cessation of embryo development. The stages of termination of a non-developing pregnancy correspond to the stages of spontaneous abortion:
threatened miscarriage;
A miscarriage that has begun
Abortion in progress
incomplete abortion.

A complete abortion during a missed pregnancy due to pathogenetic reasons is not isolated.

DIAGNOSIS OF MISTAKE PREGNANCY

Early diagnosis of non-developing pregnancy is of great practical importance, since it helps to reduce the time of examination of patients and reduce the risk of complications associated with a long stay of a dead fetal egg in the uterine cavity. The diagnosis of non-developing pregnancy is established on the basis of echographic data, revealing the absence of an embryo in the cavity of the fetal egg after 7 weeks of pregnancy or the absence of an embryo's heartbeat.

ANAMNESIS

Risk factors for chronic endometritis are identified: the presence of two or more medical abortions in history; sexually transmitted diseases, inflammatory diseases of the genital organs. It is necessary to conduct ultrasound, analysis of AFP, hCG proteins in the most informative terms.

PHYSICAL EXAMINATION

A decrease in cyanosis of the mucous membrane of the vagina and cervix occurs 4-5 weeks after the death of the fetus for up to 16 weeks of pregnancy and after 6-8 weeks with the death of the fetus at a later date. A decrease or lagging of the uterus from the proper size is detected with the death of the fetus up to 20 weeks and especially up to 12 weeks. AT early dates pregnancy, this occurs as a result of resorption of the fetal egg. At long periods - due to the absorption of organic matter, maceration and wrinkling of the fetus. A change in the consistency of the uterus, its compaction or softening is not considered a reliable symptom of a missed pregnancy. The opening of the cervical canal in nulliparous by 1–1.5 cm, and in those who have given birth - by 3 cm or more, is observed when a dead fetus is retained in the uterine cavity from 12 to 20 weeks. In the event of the death of the fetus for a period of more than 14 weeks and its presence in the uterine cavity for more than 4 weeks, when examining the uterus with the help of mirrors, a discharge of thick brown mucus from the cervical canal is detected. When the fetal bladder is opened, brown OM is poured out. If the death of the fetus occurred after 30 weeks and it was in the uterus for more than 2 weeks, when using the third external obstetric examination, crepitus is determined, which occurs due to the friction of the skull bones with each other.

INSTRUMENTAL STUDIES

Ultrasound is considered the most informative method for diagnosing a non-developing pregnancy, which makes it possible to detect a missed pregnancy long before the onset of clinical symptoms. With anembryony, an “empty” fetal egg is found, its diameter does not exceed 2.0–2.5 cm, and the size of the uterus corresponds to 5–7 weeks. pregnancy (type I anembryony), the absence of an embryo or visualization of its remains, given the normal growth rate of the fetal egg from 10–11 weeks of gestation (type II anembryony).

Ultrasound allows in the II and III trimesters to establish the death of the fetus immediately after its death. Signs of intrauterine fetal death, detected on ultrasonograms.

Change in the fetal head.
- Tile-like overlapping of the edges of the skull bones.
- Divergence of the edges of the bones of the skull.
- Flattening of the vaults of the skull.
- Asymmetry of the contours of the skull.
- Disappearance of the contours of the head.
- Sagging of the lower jaw.
- On the 4-5th day after the death of the fetus, the disappearance of the median structures of the brain is noted. An important sign of the duration of the stay of a dead fetus in the uterus is the figures of the cranial index (Y) characteristic of this pathology: the ratio of the biparietal size (BPR) of the fetal head to the frontal-occipital size (LZR) x 100. Normally, it exceeds 83. When a dead fetus is retained in the uterus up to 3 weeks cranial index is 74-64, with a delay of more than 3 weeks - 64.

· Change of a backbone.
- Deviation of the fetal head at an angle.
- Abnormal rotation and flexion of the head.
- Excessive curvature of the spine in the form of kyphosis.
- Pathological curvature of individual sections of the spine in the form of an arc or angle.
- Arrow-shaped straightening of the spine and the disappearance of the physiological curvature.
- Changes in the bones of the skeleton and limbs of the fetus.
- Shape change chest fetus.
- "Scattering" limbs.
- Indistinct and vague contours of the skeleton of the fetus.
- Atypical position of the fetus in relation to the center of the uterus.

· Other symptoms.
- Discrepancy between the size of the fetus and the expected gestational age.
- "Crown" around the cranial bones.
- Shadows from free gas in large vessels, cavities of the heart and fetal cranium.

It has been established that the shorter the gestation period (considering the second half of pregnancy) by the time of the death of the fetus and the period of its stay in the uterine cavity, the more strongly the individual parts of the skeleton are changed. The degree of transformation does not depend on the nature of post-mortem changes and the cause that caused the death of the fetus.

Diagnostic and prognostic value in case of missed pregnancy is ultrasonic placenography, which allows to determine the location of the placenta, its size, premature detachment of individual sections, changes in the form of cysts, infarcts, necrosis, calcification, etc.

With a frozen pregnancy, the placenta has a pronounced lobular structure due to an increase in calcification of the outer surface of the maternal part.

LABORATORY RESEARCH

In complex diagnostics, as additional tests, the determination of the levels of AFP, hCG and trophoblastic b-1-glycoprotein in the blood serum is used. With the death of the fetus, a high content of AFP is noted (2–4 times higher than the standard values) and a decrease in the level of trophoblastic b-1-glycoprotein (6–18 times) and hCG (3–9 times).

Prior to termination of pregnancy, it is necessary to carefully monitor the hemostasis system to correct possible violations.

ELISA determination of gravid proteins in blood serum

Trophoblastic b-1-glycoprotein.
- Trophoblastic b-1-glycoprotein is considered a specific marker of the fetal part of the placenta, it is synthesized by cells of cytotrophoblast and syncytiotrophoblast. Trophoblastic b-1-glycoprotein has the function of a transport protein and pronounced immunosuppressive properties. The detection of trophoblastic b-1-glycoprotein in the serum of pregnant women is possible on the 7-14th day after ovulation. In uncomplicated pregnancy, the concentration of trophoblastic b-1-glycoprotein in the blood serum increases from 10.4±1.1 µg/ml at 6–12 weeks to 281.1±4.8 µg/ml at 33–40 weeks. A decrease in the level of trophoblastic b-1-glycoprotein occurs immediately after the death of the fetal egg. A sharp decrease (by 4.3–8.6 times) is noted in pregnant women after 3 weeks of the stay of the deceased fetus in the uterus.

Placentospecific a-1-microglobulin.
- Placentospecific a-1-microglobulin is secreted by the decidua, it is considered a specific marker of the maternal part of the placenta. With an increase in the gestational age, the concentration of a-1-microglobulin gradually increases from 21–25 weeks of gestation (81.35±14.31 ng/ml), by 31–35 weeks it decreases (60.13±9.91 ng/ml) and subsequently reaches maximum values ​​by 40 weeks of pregnancy (111.19±6.13 ng/ml). In women with a missed pregnancy, the concentration of protein in the blood serum is 2.5 times higher than normal. The appearance of a high level of serum a-1-microglobulin is associated with a destructive process in the maternal (decidual) part of the placenta, which explains the increase in the level of protein in the blood plasma.

AFP.
- Determination of AFP plays a minor role in the diagnosis of non-developing pregnancy. A high concentration of protein in the blood serum indicates intrauterine death of the fetus (embryo). The highest serum level of embryonic protein is noted 3-4 days after the death of the fetus (embryo). The high content of AFP in the mother's blood (1.5–3 times higher than during physiological pregnancy) is associated with its diffusion into the OB and the mother's blood flow from the dead embryo or fetus.

· HCG.
- HCG is a specific pregnancy hormone that reflects its development. The production of the hormone serves as an indicator of the normal activity of the trophoblast, a criterion for its functional activity. During physiological pregnancy, the primitive trophoblast begins to produce hCG as early as 1 day after implantation.

The hormone concentration reaches its maximum already at 6–10 weeks of a normal pregnancy (116.01±16.12 IU/ml), then decreases and increases again at 31–35 weeks (34.91±7.36 IU/ml).
- The concentration of hCG in the blood serum in patients with missed pregnancy, compared with physiological pregnancy, is 8.6 times lower at 6–12 weeks, 3.3 times at 13–26 weeks, and 2 times lower at 28–30 weeks .7 times.
- They note a decrease in the level of PL (by 1.8–2.7 times), but in general it remains high. In patients with non-developing pregnancy, the concentration of progesterone in the blood remains at a relatively high level, and the content of estradiol is sharply reduced.

The diagnostic value of the study increases with repeated determinations. In a cytochemical study, a feature of the leukocyte formula in women with missed pregnancy is an increase in monocytes, a decrease in basophils and eosinophils, and an increase in ESR.

HEMOSTASIS DISORDERS IN NON-DEVELOPING PREGNANCY

LABORATORY DIAGNOSIS OF BLOOD THROMBOGENIC ACTIVITY (INTRAVASCULAR HEMOSTASIS MECHANISM)

Many authors believe that bleeding that occurs during artificial termination of pregnancy in women with intrauterine fetal death is due to a violation of the vascular platelet and plasma coagulation links of hemostasis, a violation of the fibrinolysis system.

Intravascular conditions of hemostasis in non-developing pregnancy are studied in a complex way: by biochemical and electrocoagulographic methods, while determining the time of blood clotting, the time of plasma recalcification, the activity of the prothrombin complex, the concentration of fibrinogen, the fibrinolytic activity of the blood, the retraction of the blood clot, and evaluate the chronometric and structural coagulation.

Express method for diagnosing DIC according to E.P. Ivanov

2 ml of venous blood is drawn into a test tube with an anchor (Fig. 24-3).

Rice. 24-3. Test tube with anchor.

The test tube, constantly warming in the hand, is turned over every 30 seconds. As soon as the blood stops flowing onto the walls, the clot is fixed at the anchor, the time of blood clotting is noted.
Norm: 5–11 min.
Hypercoagulable phase of DIC: 2–4 min.
Hypocoagulation: >11 min.
When a clot forms, the tube is fixed in a vertical position for 1 hour.
If a reddish-yellow transparent liquid with a volume of no more than 1–1.2 ml is released from the clot in the first 30 minutes, fibrinolysis and retraction are normal. If serum is not released, retraction processes (thrombocytopenia) are sharply disturbed in the blood.
If the clot is significantly dissolved in the first 30 minutes (1–2 ml) and the liquid phase differs little in color from the color of the blood clot, then fibrinolysis is increased in the blood.
With a-hypofibrinogenemia and an increase in the anticoagulant properties of the blood, the clotting time is significantly lengthened (more than 15 minutes). To determine the cause of this phenomenon, dry thromboplastin and 0.1 ml of 10% calcium chloride solution are added to 1 ml of blood at the tip of a scalpel, the resulting dense clot indicates anticoagulant activation. If the blood in the test tube does not clot for more than 1-3 minutes, a - or hypofibrinogenemia is ascertained, less often - hyperheparinemia.

To exclude hyperheparinemia, 0.1 ml of a 1% solution of protamine sulfate is added to the test tube. If after 1–2 minutes the blood coagulates, this indicates the presence of hypocoagulation due to hyperheparinemia, the patient must be given intravenous protamine sulfate (1 ml of protamine sulfate neutralizes 1000 IU of heparin).

The pathogenetic basis for the prevention of coagulopathic bleeding is the elimination of the direct cause of the activation of the hemostasis system (dead fetal egg), the relief of thrombinemia, the deficiency of blood coagulation components and their inhibitors.

DIFFERENTIAL DIAGNOSIS

Differential diagnosis is carried out with the onset of miscarriage, trophoblastic disease, ectopic pregnancy, violations of menstrual function against the background of inflammatory processes of the internal genital organs.

INDICATIONS FOR CONSULTATION OF OTHER SPECIALISTS

Consultation of other specialists is necessary if the patient has extragenital diseases. With pronounced deviations of hemostasis - consultation of a hemostasiologist.

EXAMPLE FORMULATION OF THE DIAGNOSIS

Non-developing pregnancy 8 weeks.

TREATMENT OF MISSED PREGNANCY

Treatment of a non-developing pregnancy consists in the evacuation of a dead fetal egg and the appointment of anti-inflammatory therapy.

GOALS OF TREATMENT

The goal of treatment is the gentle evacuation of the fetal egg, the fight against endometritis.

INDICATIONS FOR HOSPITALIZATION

All patients with an established missed pregnancy are subject to hospitalization as soon as possible.

NON-DRUG TREATMENT

There is no non-drug treatment for non-developing pregnancy.

SURGERY

With a frozen pregnancy up to 14-16 weeks, the fetal egg is evacuated simultaneously with the help of instrumental emptying of the uterine cavity, with the expansion of the cervical canal and curettage, or vacuum aspiration is used. In both cases, hysteroscopic control is necessary. During hysteroscopy, the localization of the fetal egg, the state of the endometrium are assessed, then the fetal egg is removed with the targeted taking of histological material from the placental bed and washing the uterine cavity with an antiseptic solution (Fig. 24-4, see color insert). Antibiotics are given as indicated.

Rice. 24-4. Non-developing pregnancy in the uterine cavity.

MEDICAL TREATMENT

When terminating an undeveloped pregnancy in the second trimester, use:
intraamnial administration by transcervical or transvaginal amniocentesis of 20% sodium chloride solution or PG;
The use of an antiprogestogen in combination with PG;
· isolated application of PG.

One of the most effective methods emptying of the uterus during antenatal death of the fetus is considered intraamnal administration of drugs that trigger labor activity. Apply the introduction of 50 IU of dinoprost by transabdominal access. An alternative scheme is transabdominal amniocentesis with the removal of about 10 ml of water for each week of pregnancy and the introduction of a 20% sodium chloride solution at the rate of 10 ml for 1 week of pregnancy + 10% of the calculated volume. This algorithm is applicable for a normal amount of RH. With polyhydramnios, it is recommended to introduce a smaller amount of hypertonic solution, compared with the amount of water received by 10–15%. With oligohydramnios, the amount of the injected solution may exceed the volume of the excreted fluid, but be 10 ml for each week of pregnancy.

When opening the fetal bladder, this method is appropriate. Manipulation is performed under ultrasound control.

Contraindication - suspicion of adhesions in the pelvis. Curettage of the uterine cavity after 14–16 weeks in the absence of remnants of the fetal egg and signs of a systemic inflammatory response by ultrasound is not advisable.

INDICATIONS FOR CONSULTATION OF OTHER SPECIALISTS

Consultation of a specialist is necessary with the development of coagulopathic complications, the presence of severe extragenital diseases.

APPROXIMATE TIMES OF INABILITY TO WORK

Disability 10-14 days, depending on the severity of endometritis and coagulopathy disorders.

FURTHER MANAGEMENT

The effectiveness of treatment is evaluated echographically. When using hysteroscopic control during emptying of the uterine cavity, complications develop extremely rarely (Fig. 24-5).

Rice. 24-5. Echographic picture on the 3rd day after curettage of the walls of the uterine cavity with an undeveloped pregnancy with hysteroscopic control.

Despite the position of the retroflexio uterus, the cavity is not expanded, the thickness of the M-ECHO is 3 mm. The position of the uterus is anteflexio, the cavity is expanded, M-ECHO is heterogeneous, up to 1.0 cm.

INFORMATION FOR THE PATIENT

Given the low-symptom and latency of endometritis, it is necessary to conduct a standard examination even in the absence of complaints:
microscopic examination of smears;
· bacteriological research;
PCR diagnosis of STIs;
study of the level of hormones;
Determination of the immunoreactivity of the organism;
definition of hemostasiogram;
· Ultrasound of the pelvic organs.

FORECAST

When carrying out rehabilitation therapy in the postoperative period, pregnancy occurs in approximately 85% of cases, childbirth - in 70% of cases. Without rehabilitation therapy - in 83 and 18%, respectively.