Obstetrics and Gynecology - A. M. Hromova 2000

Miscarriage and Post-term Pregnancy
Miscarriage
Treatment for Threatened Miscarriage in the First and Second Trimesters

The first trimester is widely considered the most critical and delicate period of Pregnancy. Therefore, any medical Treatment during this time must be carefully evaluated to avoid potential teratogenic or embryotoxic effects on the fetus. Given that a high proportion of spontaneous miscarriages occurring at 2-4 weeks of gestation are caused by embryonic chromosomal abnormalities, pregnancy-preservation therapy during this window is generally unjustified.

Treatment for pregnant women with a history of recurrent or complicated pregnancy loss should ideally begin before clinical signs of threatened Miscarriage appear. Early hospitalization is essential to conduct a comprehensive evaluation, identify the underlying cause of the pathology, and initiate pathogenetic treatment. Medications, including hormonal agents, must be prescribed strictly according to indications and in minimal effective doses.

In cases of threatened miscarriage During the first trimester, regardless of the Etiology, treatment must be comprehensive and multifaceted:

1. Strict bed rest.

2. A supportive and calming regimen, achieved through the administration of sedatives (such as herbal decoctions or infusions of motherwort or valerian). In the second trimester, The Use of trioxazine, tozepam, or seduxen (diazepam) may be considered.

3. Spasmolytic therapy is indicated for all patients regardless of the underlying cause of pregnancy loss: no-spa (drotaverine) 0.04 g 3 times daily, or suppositories containing papaverine hydrochloride 0.02 g 3-4 times daily. Severe pain symptoms require the administration of spasmolytics via intramuscular injection.

4. Hormonal correction therapy is indicated only when hormonal insufficiency is confirmed as the cause of pregnancy loss. Prophylactic administration of hormonal drugs is discouraged. The choice of medication and dosage is tailored to the gestational age and diagnostic test results.

5. Integration of non-pharmacological therapies: acupuncture, iontophoresis, endonasal galvanization, and electroanalgesia.

6. Immunotherapy, including Skin allograft transplantation and immunotherapy using the partner's lymphocytes.

For women presenting with ovarian hypofunction, genital infantilism, or reproductive organ anomalies, microfolin (ethinylestradiol) in small doses of 0.0125-0.025 mg daily is prescribed starting from the 5th week of gestation. From the 7th week, turinal (allylestrenol) is added at a dose of 0.005 g (1-2 tablets) daily. Alternatively, a 0.1% progesterone solution may be used in individualized dosages, or utrogestan (200-600 mg daily up to 12 weeks of gestation).

In cases of insufficient hCG production, choriogonin is administered intramuscularly at 750-1000 IU twice a week. For habitual pregnancy loss, immediately after pregnancy is diagnosed (no later than the 8th week), administration of 10,000 IU of Profasi is indicated, followed by a maintenance dose of 5,000 IU twice weekly up to the 14th week of gestation. When treating a threatened miscarriage, Profasi according to this schedule is prescribed only if the initial pathological signs appeared before the 8th week of pregnancy. Hormone dosages must be adjusted based on the patient's hormonal status. Uncontrolled use of hormonal medications causes irreparable harm.

Hormone therapy is generally continued until 15-16 weeks of gestation—marking the completion of placental formation—thereby serving as prophylaxis against primary Fetoplacental insufficiency. Microfolin is discontinued at 12-14 weeks, and turinal at 15-16 weeks. In the absence of signs indicating a threatened miscarriage and upon normalization of hormonal parameters, hormone therapy may be discontinued even earlier.

For an inevitable or onset miscarriage at 5-10 weeks of gestation, treatment begins with estrogenic hemostasis: on the 1st day, 1 ml of a 0.1% estradiol dipropionate solution is administered intramuscularly 3 times a day (every 8 hours); on the 2nd day, twice a day (every 12 hours); and on days 3-4, once a day. Afterward, microfolin can be prescribed in combination with progestogens. Hormone therapy is administered concurrently with spasmolytic (no-spa, baralgin, spazmalgin) and hemostatic (dicynone, etamsylate, vikasol, epsilon-aminocaproic acid) therapies. To prevent fetoplacental insufficiency, patients are prescribed 50 mg of cocarboxylase in 20 ml of a 40% glucose solution intravenously for 10 days, Methionine 0.5 g 3 times daily, and ascorutin 1 tablet 3 times daily.

In cases of adrenal hyperandrogenism, glucocorticoids (dexamethasone, prednisolone) must be added to the comprehensive preservation therapy. Ideally, treatment should begin during preconception counseling as preparation for a planned pregnancy to allow individualized dose titration and ensure adequate secretory transformation of the endometrium. Low doses of Hormones are recommended—for example, dexamethasone 0.5 mg or 0.375 mg (1 or 3/4 tablet) until 17-Ketosteroid (17-KS) excretion levels normalize, followed by a gradual tapering to a maintenance dose of 0.125 mg. Once 17-KS excretion levels normalize in pregnant women with hyperandrogenism diagnosed during pregnancy, corticosteroid therapy should be maintained until 32-33 weeks, with dose reduction beginning at 28-30 weeks.

Because women with adrenal-origin hyperandrogenism already exhibit endogenous progesterone levels above the norm, administering exogenous progesterone as part of their hormonal correction therapy is unjustified. In early gestation (5-6 weeks), if ovarian hypofunction signs are detected in patients presenting with a threatened miscarriage and adrenal hyperandrogenism, combination therapy using dexamethasone (or prednisolone) with microfolin is required. In cases of significant ovarian insufficiency, individualized doses of turinal (5-10 mg daily) are appropriate, guided by hormonal or colpocytological findings. Critical periods during the gestation of women with hyperandrogenism occur at 16, 20, and 28 weeks, coinciding with naturally elevated 17-KS excretion driven by fetal and maternal adrenal and Pituitary Hormones.

Concurrently with hormone therapy, treatment aimed at improving uteroplacental Circulation must be implemented. Acupuncture and Hyperbaric Oxygenation should be administered with caution in these patients, as these Procedures stimulate the maternal adrenal cortex, which can lead to increased 17-KS excretion.

Because pregnancy loss of any etiology involves immunological disruptions between the maternal Organism and the fetus, incorporating immunocorrective Methods into preservation therapy is highly advisable. Since 1969, the transplantation of a male skin flap, proposed by V.I. Govallo, has been utilized. Skin grafting stimulates the appearance of a protective blocking factor in the maternal serum, acting as an additional antigenic stimulus. In 1981, the author proposed intradermal immunization of the woman with paternal Blood lymphocytes to treat spontaneous miscarriages. This method offers advantages over skin flap transplantation due to its simplicity, lower invasiveness, and The ability to quantify the administered antigen.

To enhance treatment efficacy for women with pregnancy loss across all gestational ages, turinal—a substance highly effective in upregulating the suppressor T-lymphocyte subpopulation—is used alongside progesterone and hCG. This combined approach is particularly effective in treating recurrent miscarriage. In early pregnancy, turinal should be prescribed in low doses (5-15 mg daily).

Immunosuppressive therapy includes the administration of placental gamma globulin (5-6 ml intramuscularly), polisul (1 tablespoon 3 times daily), and glucocorticoids (prednisolone, dexamethasone). Additionally, intravenous infusions of immunosorbents (polyglyukin, reopolyglyukin) are administered once a week for a course of 5-6 infusions, alongside desensitizing therapy.

Methods of treatment for patients with cervical incompetence (cervic Isthmic insufficiency)

Both conservative and surgical approaches are employed to manage cervical incompetence. Surgical correction methods are categorized into 3 groups:

- Procedures that narrow the functionally incompetent internal cervical os (Shirodkar, Mc Donald, and Lyubimova methods);

- Suturing/cerclage of the external cervical os (Szendi and Baden methods);

- Procedures that construct muscular duplications on the lateral aspects of the cervix (Teryan's method as modified by Oryokhov and Karakhanova).

Indications for surgical intervention:

1. A history of spontaneous miscarriages in the second trimester of pregnancy and premature birth.

2. The Emergence of structural Changes in the cervix (centering, shortening, softening, dilation of the external os or cervical canal) observed during dynamic monitoring of the patient.

Contraindications for Surgical treatment:

1. Obstetric and extragenital pathologies that render carrying the pregnancy dangerous for the woman.

2. Bleeding during pregnancy.

3. Fetal malformations confirmed by ultrasound.

4. Missed abortion (non-developing pregnancy).

5. Increased uterine tone (hypertonus).

6. Grade III and IV vaginal cleanliness, as well as the presence of pathological and conditionally pathogenic microflora in the cervical canal.

The timing of the surgery is determined individually, depending on the onset time of the pathology and the Specific features of the patient's obstetric history.

Surgical correction of cervical incompetence is usually performed between 11 and 27 weeks of pregnancy. A more favorable subsequent course of pregnancy is observed with surgical treatment performed between 11 and 17 weeks, when significant shortening and dilation of the cervix are absent.

Postoperative management includes the administration of antispasmodics (No-Spa 0.04 mg 3 times daily, papaverine hydrochloride 2% - 2 ml intramuscularly or in suppositories, methacin 0.1% - 1 ml 2–3 times daily, baralgin 2 ml, gangleron 2 ml), prostaglandin inhibitors (aspirin 0.5 g 3 times daily; indomethacin: 50 mg 4 times daily on the 1st day, 50 mg 3 times daily on the 2nd day, 50 mg at bedtime on the 3rd, 4th, and 5th days). Tocolysis is performed using ß-adrenomimetics when necessary. To increase oxytocinase activity and inhibit Calcium Ions during uterine irritability, a 2% magnesium sulfate solution (200–400 ml) or sinusoidal modulated current magnesium Electrophoresis using the "Amplipulse-3" and "Amplipulse-4" devices is utilized. During the first 3–4 days following the surgical correction of cervical incompetence, progesterone 1% solution 1 ml is administered intramuscularly; daily vaginal treatment with a 3% hydrogen peroxide solution, 1% aqueous chlorhexidine solution, 0.6% sodium hyposulfite solution, or 1:5000 furatsilin solution is indicated.

Antibacterial therapy is prescribed if the surgery is performed amid significant structural changes in the cervix with prolapse of the amniotic sac, or in the presence of cervical erosion. The drugs of choice are Semisynthetic Penicillins (ampicillin 2 g daily for 5–7 days).

In the event of an uncomplicated postoperative period, the pregnant woman may be discharged for outpatient follow-up at the antenatal clinic 7 days after cervical cerclage. If the surgery is performed under unfavorable conditions (significant structural changes of the cervix, prolapse of the amniotic sac), pregnant women should remain hospitalized for 1–1.5 months following surgical correction.

During follow-up at the antenatal clinic or in the hospital, cervical examinations are performed every 2 weeks. The sutures are removed at 37–38 weeks of gestation.

In cases of mild pathology, non-surgical correction methods (such as pessaries or Hodge/Goltz rings) are occasionally used. In cases of pronounced manifestations of cervical incompetence, pessaries or rings may be applied after cervical cerclage to reduce pressure on the cervix and prevent suture tearing through the tissue.