ABORTION

Abortion - termination of pregnancy in terms of up to 28 weeks, counting from the first day of the last menstruation. There are spontaneous and artificial abortion.

Spontaneous abortion (miscarriage, spontaneous abortion) - spontaneous abortion until 28 weeks. Depending on the term of termination of pregnancy, the early (up to 12 weeks) and late (from 12 to 28 weeks) spontaneous abortion are conventionally distinguished. Interruption of pregnancy after 28 weeks is usually called premature birth . Spontaneous abortion, repeated during the next one after the other pregnancies (more than 2 times), is called a habitual miscarriage. Its causes may be dysfunction of the ovaries, adrenal cortex, inflammatory diseases of the genitals, previous artificial abortions, especially during the first pregnancy, and other factors.

The mechanism of spontaneous abortion is different. In some cases, first there are contractions of the uterus, causing a detachment of the fetal egg. In other cases, contractions of the uterus are preceded by the death of the fetal egg (with toxicoses of pregnant women , infectious diseases of the pregnant woman, etc.). Sometimes the detachment and death of the fetal egg and contraction of the uterus occur simultaneously.

The following stages of spontaneous abortion stand out: threatening, started, abortion in progress, incomplete and complete abortion. When threatening abortion, a feeling of heaviness or weak pulling pains in the lower abdomen and the area of ​​the sacrum is noted, with abortion in later terms may be pains of a cramping character. Bloody discharge is slight or absent. The cervix of the uterus is not shortened, the outer yawn is closed, the tone of the uterus is elevated. The size of the uterus corresponds to the period of pregnancy.

With the onset of abortion, cramping pain and spotting are more pronounced than with menacing. Fruit egg exfoliates in a small area, so the size of the uterus corresponds to the period of pregnancy. The cervix is ​​preserved, the canal is closed or slightly ajar.

Abortion in the course is characterized by cramping pains in the lower abdomen, marked by bleeding. The fetal egg is located in the cervical canal, its lower pole can protrude into the vagina. Abortion in the course may result in incomplete or complete abortion.

With incomplete abortion, the fetal egg is partially expelled from the uterine cavity, cramping pains in the lower abdomen and bleeding of different intensity are observed. The canal of the cervix is ​​open, with a vaginal examination it freely passes the finger, the uterus is of a softish consistency, its value is less than the expected gestation period. In the uterus, the fetal membranes, the placenta, or part of it are usually retained.

With full abortion, which is more often observed in late pregnancy , a fetal egg leaves the uterine cavity, the uterus contracts, the bleeding stops.

If uterine contractions that occur after the death of the fetal egg are insufficient for its expulsion, a slow detachment of the fetal egg occurs, which can be accompanied by a prolonged uneventful uterine bleeding leading to the development of anemia . At early stages of pregnancy, a cervical abortion is possible. In this case, the external uterine ooze does not open, and the fetal egg, completely exfoliating, descends as a result of contractions of the uterus into the cervical canal, the walls of which are stretched, and the cervix becomes barrel-shaped. This type of spontaneous abortion should be differentiated from a cervical pregnancy , when a fetal egg is attached to the cervical canal.

With spontaneous abortion, it is possible to penetrate the microflora from the vagina into the uterine cavity with the subsequent development of the inflammatory process. Infected (febrile) abortion can cause generalized septic diseases. At the same time, fever , tachycardia , leukocytosis are noted , the uterus may be larger than the norm, it is painful on palpation, there are pus-like discharge from the genital tract. In the case of infection, the condition worsens, pains, chills, dyspepsia and dysuria occur, blood changes: high leukocytosis, increased ESR, purulent salpingitis, parametritis, pelvioperitonitis, sepsis .

The diagnosis of spontaneous abortion is established on the basis of the clinical picture, the data of the vaginal, vaginal-abdominal and ultrasound examinations.

In case of a threatening spontaneous abortion in the first trimester of pregnancy, treatment can be conducted in a women's consultation by organizing a "home-based hospital". In the event that within 3 to 5 days the symptoms of the threat of termination of pregnancy do not subside, the pregnant woman should be referred to a hospital. Treatment of a threatening interruption of pregnancy is complex, it includes bed rest, sedatives, antispasmodics, hormonal therapy is indicated in the first trimester, depending on the causes of the threat of interruption, hormonal parameters of blood and (or) urine, gestational age.

In case of a threatening spontaneous abortion in the II and III trimesters of pregnancy, a woman should be hospitalized, since constant monitoring of the cervix, evaluation of the fetus is necessary. For treatment use tocolytic and antispasmodics.

When spontaneous abortion begins, urgent hospitalization is indicated for any period of pregnancy . Treatment is basically the same as with a threatening miscarriage. To stop bloody discharge with an abortion in the first trimester of pregnancy, estrogen-containing drugs are used. After stopping bloody discharge or simultaneously with a microfoline prescribe progesterone or its synthetic analogue turinale. With abundant bloody discharge hormonal therapy of abortion started is not effective.

With abortion in progress, incomplete, complete and cervical abortion, instrumental removal of the remains of the fetal egg and blood clots by methods of scraping or vacuum-exochlearing, which allows to stop bleeding and prevent infection.

In uncomplicated infected abortion, the removal of the remains of the fetal egg is performed against the background of antibacterial therapy. The principle of treatment for complicated infected and septic abortion is the same as for postpartum septic infection.

With a failed abortion, prolonged waiting is unreasonable.

In the first trimester of pregnancy, the lost egg is removed instrumentally. In later terms of pregnancy, labor is performed. Before this, it is necessary to carry out a study of the blood coagulation system. After removal of the fetal egg, antibacterial therapy and the means that reduce the uterus are prescribed.

Complications . The closest complications in spontaneous abortion are uterine bleeding due to delayed parts of the fetal egg in the uterine cavity or a disorder in the blood coagulation system and the case of prolonged waiting for abortion (in severe cases, the DIC syndrome may develop - disseminated intravascular coagulation syndrome), infection of the uterus until the development of sepsis And infectious-toxic shock ; Complications associated with technical errors in scraping or delivery - perforation of the uterus, rupture of the body or cervix. Remote complications: inflammatory process in the genital organs ( salpingo-oophoritis , endometritis ), ovarian dysfunction , infertility , chorionepithelioma, exacerbation of extragenital diseases, development of rhesus sensitization during subsequent pregnancy, etc.

The prognosis of maintaining a pregnancy with spontaneous abortion depends on the stage of the process. Preservation is possible with a threatening miscarriage, less often with the onset.

After spontaneous abortion, a woman should be under the supervision of a woman's consultation doctor until the normal rhythm of menstruation is restored (under conditions of absence of any infectious complications). Three months after abortion, it is advisable to examine the condition of the reproductive system of a married couple to find out the reasons for spontaneous abortion and to take the necessary rehabilitation measures to prepare for the next pregnancy.

Artificial abortion - deliberate termination of pregnancy and a period of up to 28 weeks. Artificial abortion is one of the widely used methods of family planning and to some extent affects the level of fertility. The main reasons for artificial abortion are the desire of women to limit the number of children in the family or not have them at all, the unfavorable psychological climate in the family, the inability (or unwillingness) to combine work or study with the birth and upbringing of the child, which is especially characteristic of young families, Child, large families, illness of one member of the family, unsatisfactory material and living conditions, etc. The high frequency of induced abortions is largely due to the low level of awareness of the population about highly effective methods and means of contraception , their inaccessibility for most of the population, and the lack of a network of specialized institutions , Offices) involved in family planning, including the organization of work on contraception. Artificial abortion causes large medical and demographic and economic losses, as they lead to an increase in gynecological morbidity, infertility , contribute to the occurrence of spontaneous abortions and premature births in subsequent pregnancies, an increase in the level of maternal and perinatal mortality.

The main method of preventing artificial abortions is the introduction of modern contraceptives. The use of modern methods and contraceptive methods by women of the reproductive age leads to a decrease in artificial abortions and does not subsequently have a negative effect on women's health status, reproductive function, and fertility level. To achieve a steady decline in the level of artificial abortions is possible only if the purposeful work on contraception is combined with hygienic education of the population, especially adolescents.

Medical artificial abortion is performed by an obstetrician-gynecologist in a specialized department of the hospital, maternity hospital or a woman's consultation if the woman wishes to terminate pregnancy and for medical reasons in cases where the continuation of pregnancy and childbirth leads to a deterioration in health and threatens the life of the woman, Abnormalities of fetal development. The most common is medical artificial abortion in the early stages of pregnancy (up to 12 weeks). Interruption of pregnancy in terms exceeding 12 weeks, is carried out mainly for medical reasons. The need for abortion for medical reasons is established by the obstetrician-gynecologist in conjunction with specialists of the appropriate profile (therapist, surgeon, oncologist, psychiatrist, etc.) and the head of the medical institution after the examination of the patient in the hospital.

Artificial abortion with a gestation period of more than 12 weeks and up to 28 weeks is permitted if the birth of a child is undesirable due to certain social factors: for example, a minor pregnancy (performed with the consent of the parents), the death of the pregnant husband, the stay of a woman or her husband in custody, Maternity rights, many children (more than 5 children in the family), divorce during pregnancy, pregnancy after rape, and the presence of a disabled child in the family.

Contraindications to artificial abortion are acute and subacute inflammatory processes of the genital organs, the presence of purulent foci irrespective of their location, the term is less than 6 months after the previous termination of pregnancy, acute infectious diseases. In later terms, abortion is contraindicated if abortion during this period is more dangerous to health and life than the continuation of pregnancy and childbirth.

Before the termination of pregnancy irrespective of its term, clinical blood and urine tests, a bacterioscopy of a smear from the vagina, Wasserman's reaction and for HIV infection, determine the blood group and Rh-accessory. Before termination of pregnancy in late terms, examine the coagulating system of blood and conduct special studies, depending on the nature of the underlying disease, which served as the basis for abortion (electrocardiography, examination of the kidneys, liver, etc.).

Artificial termination of pregnancy in the early period of time is performed by methods of scraping or vacuum-exochlearing. If the menstruation is delayed for up to 20 days, abortion by the vacuum-exocculation method - the so-called mini-abortion can be performed both in the hospital and outpatient.

The closest complications during the operation of an artificial termination of pregnancy or soon after it - perforation of the uterus, bleeding. The most common complication is the left in the uterine cavity parts of the fetal egg. To prevent this complication, immediately after an abortion, an ultrasound is performed, in the case of detection of the remains of the fetal egg - revision of the uterine cavity.

Long-term complications : inflammatory diseases of the genital organs, dysfunction of the ovaries and adrenal glands, infertility , miscarriage, ectopic pregnancy , etc. In subsequent pregnancies and births, the incidence of stillbirth, asphyxia and hemolytic disease of the newborn increases . The risk group for complications is women with three or more abortions in history, suffering from inflammatory diseases of the uterine appendages, menstrual irregularities, blood diseases, previous surgical interventions on the uterus and ovaries. The method of vacuum-exochlearing (especially mini-abortion) has a number of advantages over scraping due to less traumatization of the cervix and walls of the uterus body, a reduction in the operation time, a reduction in the frequency of near and far complications.

For artificial termination of pregnancy in later periods, use a small cesarean section (with severe extragenital diseases of the pregnant woman), the introduction of a hypertonic solution of sodium chloride or preparations of prostaglandins into a fetal bladder. Preliminarily with the help of ultrasound, the localization of the placenta is clarified. Initially, amniocentesis (puncture of the bladder) is carried out and 150-150 ml (depending on the gestation period) of the amniotic fluid is removed. Then, 20% sodium chloride solution is slowly introduced into the amnion cavity in an amount 30-50 ml less than the amniotic fluid is discharged. The latent period from the introduction of the solution to the appearance of fights ranges from 17 to 21 hours. The miscarriage occurs, usually after 24 to 26 hours. Complications can be associated with technical errors (the introduction of hypertonic sodium chloride solution in the tissues, vascular bed, placenta); The same complications are observed as in the case of spontaneous abortion - bleeding, inflammatory diseases of the genital organs, cervical ruptures, exacerbation of the underlying disease, etc. Prevention of complications consists in careful preparation for surgery and accurate observance of its technique.

Introduction to the cavity of the bladder prostaglandin drugs is carried out according to the same rules as the hypertonic sodium chloride solution, but the prostaglandin drug is injected into the amnion cavity immediately after the puncture of the fetal bladder without preliminary evacuation of amniotic fluid. When using prostaglandins, miscarriage occurs faster. Complications occur less than with the introduction of hypertonic sodium chloride solution; The ingestion of prostaglandins in the tissue does not cause necrosis. There may be side effects: nausea , vomiting , diarrhea, headache .

Contraindications to the interruption of pregnancy through the introduction of drugs in the bladder are severe cardiovascular diseases, a significant increase in blood pressure, CNS, kidney, blood, bleeding due to presentation or premature detachment of the placenta, etc.

In the postabortion period it is necessary to monitor the status of the uterus, the nature of the discharge from the genital tract, the general condition of the woman. The management of the postabortion period with the termination of pregnancy in the late period is the same as the postpartum period, measures should be taken to suppress lactation, and the main disease should be treated. Rh-negative patients, irrespective of the gestational age, are prevented by rhesus-sensitization (antirezus immunoglobulin is administered in the first 48 hours after abortion).

Criminal abortion - the termination of pregnancy by the woman or other person, made outside the medical institution. A person who commits a criminal abortion to a woman is criminally liable. The cause of criminal abortion is more often the woman's desire to conceal a pregnancy. For criminal abortion use mechanical, chemical, medicines, etc. Abortion is often carried out in unsanitary conditions, which often causes severe septic complications , DIC-syndrome , infectious-toxic shock , renal insufficiency , hepatic insufficiency . In the future often occurs infertility, there are miscarriages and other complications.

Often when a criminal abortion, there are poisonings associated with the introduction of or parenterally drugs, called in everyday use "abortifacial agents." These include preparations of female sex hormones and their synthetic analogues (folliculin, methylethradiol, synestrol , diethylstilbestrol, progesterone , pregnin); Funds that stimulate the musculature of the uterus - preparations of ergot (ergotal, ergometrine, ergotamine , etc.); Preparations of the posterior lobe of the pituitary ( oxytocin , pituitrin, etc.), stipticin, spherofizin, isoverin; Funds that stimulate the uterus only when used in a toxic dose (pahikarpin, quinine ).

The clinical symptoms of poisoning with these drugs are related to their selective toxicity and accepted dose, which, as a rule, significantly exceeds the highest single and daily. Symptoms of poisoning with drugs of female sex hormones and their synthetic analogues appear when the higher daily doses exceed 10 times or more. This causes dyspeptic disorders ( nausea , vomiting ), headache , dizziness . There is an increase in blood pressure, tachycardia , orthostatic collapse is possible. With long-term administration (more than 5 to 7 days) of toxic doses of these drugs, toxic liver damage is possible. The reason for emergency hospitalization is usually the appearance of uterine bleeding.

When the drugs are poisoned by the posterior lobe of the pituitary gland, as well as by stypticin, spherophysin, and isorein, if there is a 3-4-fold excess of their daily dose, abdominal pain occurs, cardiotoxic manifestations (especially with parenteral administration) are a disorder of heart rhythm and conduction. ECG records ventricular extrasystole, various stages of atrioventricular block, ventricular fibrillation.

Possible collapse and death. The greatest toxic effect is due to the use of pachycarpine, quinine, ergot preparations in doses that increase 2 to 3 times daily.

Diagnosis of such poisonings is difficult in the absence of reliable anamnestic data, which often hide. Treatment of poisoning with "abortive drugs" is usually delayed due to late seeking medical help. Detoxification therapy includes gastric lavage through the probe, administration of 50 g of activated carbon , laxatives (with oral poisoning); Forced diuresis with urea or lasix. In severe poisoning, hemosorption is recommended on the 1st day. Symptomatic treatment is aimed at maintaining the functions of vital organs, with the appearance of uterine bleeding, an emergency curettage of the uterine cavity is indicated.

When used for artificial abortion in out-of-hospital conditions, the catheterization of the uterine cavity, followed by the introduction of solutions of antibiotics, furacilin, potassium permanganate, soap through the catheter, etc., the greatest danger is the rapid (within 2 to 3 days) development of endometritis , septic state and acute renal failure Septic abortion).