I. Definition
Abortion is defined as the termination of pregnancy at less than 28 weeks of gestation and the fetus weighing less than 1000g. It is called early abortion when it occurs before 12 weeks of gestation and late abortion when it occurs after 12 weeks of gestation. Most spontaneous abortions are an optimization tool to reduce the incidence of congenital malformations.
Etiology
(i) Genetic defects
Abnormal chromosome number, such as haploidy and polyploidy; abnormal chromosome structure, such as translocation, breakage and deletion, are common causes of early spontaneous abortion. They account for about 50% of spontaneous abortions. It often causes the embryo to degenerate or disappear during development and become an empty sac, called gestational egg blight. Or the formation of structurally abnormal embryos, leading to miscarriage.
(ii) Environmental factors
There are many external adverse factors that affect reproductive function and can directly or indirectly cause damage to the embryo or fetus. Excessive exposure to certain harmful chemical substances (such as arsenic, lead, benzene, formaldehyde, ethylene oxide, etc.) and physical factors (such as radiation, noise and high temperature, etc.) can cause miscarriage.
(C) maternal factors
1. Poor maternal constitution. Severe malnutrition, anemia, heart disease, nephritis, hypertension, and even heavy mental trauma and extreme emotional instability can lead to miscarriage.
2. Acute maternal infectious diseases. Such as viral infection, pneumonia, typhoid fever, hepatitis, etc. Bacteria, viruses and toxins can enter the blood circulation of the fetus through the placenta, causing fetal death and miscarriage.
3.Disease of the uterus. Malformation of the uterus, such as bicornuate uterus, unicornuate uterus, longitudinal uterus, etc.; multiple uterine fibroids, especially those protruding to the submucosa, can affect the growth and development of the fetus in the uterus. Damage to the endometrium caused by multiple abortions and scrapings, resulting in miscarriage due to poor development of the metaplasm after pregnancy. Loosening of the endocervix or deep laceration of the cervix is often the cause of late miscarriage.
4.Endocrine factors. Low thyroid function and luteal insufficiency can often affect the meconium, placenta and fetal development and cause miscarriage.
5, immune factors. Pregnancy such as homozygous transfer, there is a complex and special immunological relationship between the embryo and the mother, and this relationship makes the embryo not be rejected. If the mother and child are immune maladjusted, it can cause maternal rejection of the embryo and miscarriage. If the mother and child have a blood group incompatibility, it can lead to miscarriage.
III. Pathology
1. Within 8 weeks of gestation, the placental villi are not firmly connected with the endometrium, and the pregnancy products can be separated from the uterine wall and expelled intact, with little bleeding.
2. From 8 to 12 weeks of gestation, the placental villi are well developed and firmly connected with the meconium, so the pregnancy products are not easily separated and discharged, and some tissues remain in the uterine cavity and affect the uterine contraction, resulting in more bleeding.
After 12 weeks of gestation, the placenta is fully formed and abortion is preceded by abdominal pain and then discharge of the fetus and placenta. Sometimes, due to repeated bleeding of the bottom mucosa, the coagulated blood clot wraps around the fetal mass and forms a blood-like fetal mass that stays in the uterine cavity.
IV. Diagnostic points
(I) Diagnosis
1.History of menopause with early pregnancy reaction, positive urine pregnancy test or blood HCG, pregnancy can be confirmed.
2.Symptoms such as vaginal bleeding, abdominal pain, or tissue discharge.
3.Clinical classification can be made according to clinical symptoms, physical signs, the amount of bleeding, the degree of opening of the uterus and the size of the uterus.
4.B ultrasound can assist in the diagnosis of intrauterine pregnancy.
5.Scraping of the uterus can be seen by visual or pathological examination of the villi.
6, cervical secretion culture or blood culture with pathogenic bacteria.
(B) Critical illness indicators
1, vaginal hemorrhage, often occurs in incomplete abortion after 8 weeks of gestation, when the pulse rate is fast, blood pressure drops, and shock symptoms appear.
2. High fever and chills, mostly occurring in infected abortions, with shock symptoms in severe cases.
3.Vaginal bleeding after the fetus or placenta is expelled, suggesting the occurrence of diffuse intravascular coagulation (DIC), which mostly occurs in overdue abortion or infected abortion.
(C) Differential diagnosis
1, first identify various types of abortion (see Table 8-1)
2, ectopic pregnancy. There are three main symptoms: abdominal pain, menopause, and irregular vaginal bleeding. There is pallor, wet and cold extremities, weak pulse and decreased blood pressure with significant pressure pain, rebound pain or mobile turbid sounds in the lower abdomen when there is massive bleeding. Ultrasound shows no fetal sac in the uterus, mixed mass in the adnexa, and blood accumulation in the rectal uterine recess. Posterior vault puncture may extract non-coagulated blood.
3. Gravidity. Irregular vaginal bleeding after menopause, heavy nausea and vomiting, uterus enlargement does not match with the month of menopause, soft texture. The fetal heart cannot be heard in the fifth month of pregnancy, only the murmur of uterine blood flow can be heard, and the reflection image of fetal body and placenta is not seen in ultrasound examination, only snowflake-like shadow called “falling snowflake”.
4.Other. Functional uterine bleeding, uterine fibroids, endometritis, etc. can also cause irregular vaginal bleeding and lower abdominal pain, which should be differentiated with clinical signs and medical history and patient’s age.
V. Treatment points
Active treatment should be carried out according to the type of miscarriage.
(A) Pre-eclampsia miscarriage
1.Early stage
(1) Actively protect the fetus, take bed rest, prohibit sexual intercourse, relieve the burden of thought, regularly recheck urine and blood HCG and perform ultrasound examination.
(2) Progesterone 20mg, intramuscular injection, once a day if luteinizing body function is insufficient. Chorionic gonadotropin 1000IU intramuscularly once daily. Vitamin E 10-30mg, 3 times daily or 100mg once daily orally.
(3) For thyroid insufficiency, give thyroxine tablets 0.03-0.06g orally 1-2 times a day.
(4) Phenobarbital 0.06g, orally 3 times a day.
2.Late stage
(1)Bed rest.
(2) 25% magnesium sulfate 10-15ml + 10% glucose 20ml intravenous push, followed by 25% magnesium sulfate 40-60ml + 5% glucose 1000ml intravenous slow drip.
(3)Salbutamol sulfate 2.4-4.8mg orally every 6-8 hours.
(4) Chinese medicine diagnosis and treatment.
(5) For Rh blood group incompatibility, Inchon Punch can be taken orally, 1 packet twice daily.
(2) Refractory abortion and incomplete abortion
1.In principle, the uterus should be cleared immediately under the condition of infusion, and the uterine contraction can be applied appropriately during the operation.
2. Closely observe the general condition, blood pressure and pulse rate of the mother.
3.If the woman is in shock, she should be given fluids and blood immediately to correct the shock, and then carry out uterine removal.
4.Send the scrapings for pathological examination.
5.After the operation, pay attention to the amount of vaginal bleeding and body temperature, and give antibiotics to prevent infection.
6.When intrauterine infection is suspected, semi-recumbent position should be taken to facilitate drainage.
(C) Induced abortion
1, to understand the coagulation function, early detection of DIC, with DIC manifestations according to DIC treatment.
2. The sensitivity of the uterus to oxytocin should be improved before induction of labor begins.
(1) Oral hexenestrol 5-15mg/dose 2-3 times daily x 3-5 days.
(2) Estradiol benzoate 2-4mg/dose, intramuscularly, 2 times daily x 3 days.
(3) Sodium prandial sulfate 100-200mg in 5% glucose 10-20ml, diluted and slowly pushed intravenously for 3 days.
3. Expel the fetus as early as possible. The uterus is less than 3 months of gestation size can be directly scraped, more than 3 months of gestation size should be induced first.
4.When there is chronic DIC, the decision of treatment should be made according to the coagulation and fibrinolytic examination index before induction of labor. Generally give heparin 25-50mg per day, 1-2 days after the induction of labor. Fresh blood should be given when blood transfusion is needed, and fibrinolytic inhibitors should be given when fibrinolysis is hyperactive.
(iv) Complete abortion
The excretion should be sent for examination and no special treatment is usually done. In case of high blood loss, appropriate rehydration, anti-inflammatory and anemia correction should be performed.
(E) Infected abortion
If there is not much bleeding, the uterus should be cleared after antibiotics are given to control the infection. If there is a lot of bleeding or if the infection is not controlled by giving a lot of antibiotics, the contents of the uterine cavity can be clamped out with oval forceps, but the uterine wall should not be scratched with a scraper to avoid the spread of infection, and the uterus can be removed if necessary.
(F) Habitual abortion
Treatment for the cause. In cases of luteal insufficiency, apply progesterone as early as possible to prevent miscarriage. For uterine malformations such as bicornuate uterus and longitudinal uterus, corrective surgery can be performed before pregnancy and postoperative contraception for 1 year. If the endocervix is loose, endometrial suturing should be performed at 12-20 weeks of gestation.