Etiology: why pregnancy terminates
The causes of pregnancy loss are multifaceted and often require comprehensive evaluation. The main groups of factors include:
- Infectious: persistent viruses (HSV, CMV), opportunistic flora, and mixed infections causing chronic endometritis.
- Endocrine: thyroid dysfunction, hyperandrogenism, hyperprolactinemia, and luteal phase defect.
- Immunological: antiphospholipid syndrome (APS), presence of antibodies to hCG or TPO, as well as spousal HLA compatibility.
- Genetic: karyotype abnormalities (trisomies, monosomies, translocations).
- Uterine pathology: uterine malformations, intrauterine synechiae, myoma, and cervical insufficiency (CI).
- Thrombophilias: congenital hemostasis defects, including coagulation factor mutations and hyperhomocysteinemia.
The key pathogenetic mechanism of most factors is impaired migration of cytotrophoblasts into spiral arteries, which impedes normal placental development.
Stages of termination: clinical diagnosis
To select the management tactics, it is important to determine the stage of the process:
- Threatened abortion: lower abdominal pain, but no spotting. The internal os is closed.
- Inevitable abortion: accompanied by spotting due to detachment of the gestational sac.
- Abortion in progress: the gestational sac shifts to the lower parts of the uterus, accompanied by heavy bleeding.
- Incomplete abortion: parts of the gestational sac remain in the uterine cavity, and the cervix is dilated.
- Complete abortion: the gestational sac has completely passed, the uterine cavity is empty, and the os is closed.
The main diagnostic methods are ultrasound and monitoring of β-hCG levels.
Management tactics
The goal of therapy in threatened and inevitable abortion is to preserve the pregnancy. The basic approach includes bed rest, antispasmodics, and sedatives. Gestagens and antifibrinolytics are added for inevitable abortion.
In abortion in progress or incomplete abortion, instrumental removal of the uterine cavity contents is indicated, preferably by vacuum aspiration. In complete abortion, surgical intervention is not required if ultrasound confirms the absence of residual gestational tissue.
T-I-P-I-C: Threatened, Inevitable, abortion in Progress, Incomplete, Complete.
Class and exam questions
How does a threatened abortion differ from an inevitable abortion?
In threatened abortion, spotting is absent, and the internal os is closed. In inevitable abortion, detachment of the gestational sac occurs, which is accompanied by spotting.
Is curettage necessary in a complete abortion?
No, if ultrasound shows the uterine cavity is empty, surgical treatment is not performed. Instrumental removal is indicated only if residual gestational tissue is present.
Why is it important to check hemostasis in pregnancy loss?
Congenital thrombophilias (e.g., Factor V Leiden mutation or protein C deficiency) impair placental blood supply, which is a frequent cause of pregnancy termination.
What else to study on this topic
- The role of spousal HLA typing in immunological pregnancy loss.
- Differential diagnosis with ectopic pregnancy.
- Specifics of pregnancy management in cervical insufficiency.
- Impact of occupational hazards on reproductive function.
- Methods for correcting hyperandrogenism during pregnancy.
Master the entire topic in the "Obstetrics and Gynecology" course
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