2. 22
Miscarriage or spontaneousMiscarriage or spontaneous
abortion is defined as lossabortion is defined as loss
of a pregnancy withoutof a pregnancy without
outside intervention in theoutside intervention in the
term between the beginningterm between the beginning
of pregnancy and 37 weeksof pregnancy and 37 weeks
gestation.gestation.
3. 33
- Early spontaneous abortion:- Early spontaneous abortion:
spontaneous abortion that occurs inspontaneous abortion that occurs in
the first 11 weeks of pregnancy + 6the first 11 weeks of pregnancy + 6
days;days;
- Late spontaneous abortion: from 12- Late spontaneous abortion: from 12
to 21 weeks + 6 days;to 21 weeks + 6 days;
- Preterm delivery: from 22 to 36- Preterm delivery: from 22 to 36
weeks + 6 days (154 – 259 days).weeks + 6 days (154 – 259 days).
10. 1010
Spontaneous abortionSpontaneous abortion
(miscarriage)(miscarriage) –– expulsion ofexpulsion of
embryo/fetusembryo/fetus in the term ofin the term of
gestation up to 22 weeks or up togestation up to 22 weeks or up to
500 grams of weight regardless of500 grams of weight regardless of
presence or absence of vitalpresence or absence of vital
signs.signs.
12. 1212
Habitual abortionHabitual abortion
(recurrent miscarriage)(recurrent miscarriage) ––
is normally diagnosed afteris normally diagnosed after
two or more pregnanciestwo or more pregnancies
end in miscarriages.end in miscarriages.
14. 1414
Table 1.Table 1. Signs of pregnancy inSigns of pregnancy in
the first trimesterthe first trimester
Case historyCase history
datadata
ObjectiveObjective
examinationexamination
datadata
UltrasonograpUltrasonograp
hy (US)hy (US)
LaboratoryLaboratory
tests datatests data
Delay ofDelay of
menstruation.menstruation.
Enlargement ofEnlargement of
uterus, changeuterus, change
of its form andof its form and
consistencyconsistency..
Embryonic/fetalEmbryonic/fetal
visualizationvisualization
(according to(according to
gestation term).gestation term).
PositivePositive
pregnancy test.pregnancy test.
Nausea,Nausea,
vomiting,vomiting,
changed sensechanged sense
of smell andof smell and
tastetaste
Softening ofSoftening of
cervix. Cyanosiscervix. Cyanosis
of vaginal walls.of vaginal walls.
Enlargement andEnlargement and
engorgement ofengorgement of
mammary glands.mammary glands.
Increase ofIncrease of
human chorionichuman chorionic
gonadotropingonadotropin
(HCG) level in(HCG) level in
blood serum.blood serum.
15. 1515
Threatened abortion.Threatened abortion.
Patient complaints.Patient complaints.
1 Abdominal cramps, after 16 weeks1 Abdominal cramps, after 16 weeks
of gestation possible cramp-likeof gestation possible cramp-like
pain.pain.
2 Weak or moderate bloody2 Weak or moderate bloody
discharge from genital tractsdischarge from genital tracts
3 Delay of menstruation.3 Delay of menstruation.
16. 1616
Examination.Examination.
Speculum examination.Speculum examination.
1 External orifice of uterus is closed.1 External orifice of uterus is closed.
2 Weak or moderate bloody discharge.2 Weak or moderate bloody discharge.
Bimanual vaginal examination.
1 The uterus is irritable, the uterine tone is
heightened.
2 The size of uterus corresponds to the term of
gestation.
17. 1717
US: general signs.US: general signs.
1 Cushion-like local myometrial1 Cushion-like local myometrial
thickening protruding into thethickening protruding into the
uterine cavity.uterine cavity.
2 Gestational sac contour2 Gestational sac contour
deformation.deformation.
3 Visualization of placental or3 Visualization of placental or
chorionic detachment areas.chorionic detachment areas.
18. 1818
Table 2.Table 2. Prognostic criteria forPrognostic criteria for
pregnancy progression.pregnancy progression.
SignsSigns FavorableFavorable
prognosisprognosis
UnfavorableUnfavorable
prognosisprognosis
Case historyCase history Pregnancy inPregnancy in
progressprogress
SpontaneousSpontaneous
abortions inabortions in
pastpast
history;Woman’history;Woman’
s age › 34s age › 34
years.years.
19. 1919
SonographicSonographic PresentPresent
heartbeat;heartbeat;
absence ofabsence of
bradicardia; thebradicardia; the
size of thesize of the
embryoembryo
corresponds tocorresponds to
the size of thethe size of the
gestational sac;gestational sac;
the sac isthe sac is
dynamicallydynamically
developingdeveloping
Heartbeat absent;Heartbeat absent;
bradicardia; emptybradicardia; empty
emty gestationalemty gestational
sac; the size of thesac; the size of the
embryo does notembryo does not
correspond to thecorrespond to the
size of the sac;size of the sac;
absence of fetalabsence of fetal
sac growth after 7-sac growth after 7-
10 days;10 days;
subchorionicsubchorionic
hematoma.hematoma.
20. 2020
BiochemicalBiochemical Normal level ofNormal level of
biochemicalbiochemical
markers.markers.
Serum HCG level isSerum HCG level is
below normal for thebelow normal for the
corresponding term ofcorresponding term of
gestation; HCG levelgestation; HCG level
increase is below 66%increase is below 66%
within 48 hours (up towithin 48 hours (up to
8 weeks of gestation)8 weeks of gestation)
or HCG levelor HCG level
decreases;decreases;
progesterone level isprogesterone level is
below normal rate forbelow normal rate for
the term of gestationthe term of gestation
and decreases inand decreases in
dynamics.dynamics.
21. 2121
IMPORTANT!!!IMPORTANT!!!
When clinical signs of threatenedWhen clinical signs of threatened
abortion are present in the term ofabortion are present in the term of
gestation less than 8 weeks and thegestation less than 8 weeks and the
prognosis for pregnancy progressionprognosis for pregnancy progression
is unfavorable it is not recommendedis unfavorable it is not recommended
to start a pregnancy maintenanceto start a pregnancy maintenance
therapy.therapy.
- high rate of chromosomal anomalies- high rate of chromosomal anomalies
in this term of gestation;in this term of gestation;
- low efficiency of the therapy.- low efficiency of the therapy.
22. 2222
Table 3.Table 3. Therapy applied inTherapy applied in
threatened abortion cases.threatened abortion cases.
Medical approachMedical approach EfficiencyEfficiency
Bed rest and total sex abstinence.Bed rest and total sex abstinence. According to various researchAccording to various research
data the efficiency is moderate.data the efficiency is moderate.
Spasmolytics (papaverineSpasmolytics (papaverine
hydrochloride, riabal, etc);hydrochloride, riabal, etc);
There is no evidence that thisThere is no evidence that this
approach can be used efficientlyapproach can be used efficiently
and safely as means ofand safely as means of
miscarriage prevention.miscarriage prevention.
Hormonal therapy (progesteroneHormonal therapy (progesterone
or its synthetic analogs):or its synthetic analogs):
- 1% progesterone solution,- 1% progesterone solution,
intramuscularly; utrogestanintramuscularly; utrogestan
(vaginally or orally);(vaginally or orally);
- dufaston (orally).- dufaston (orally).
Indications for progesterone use:Indications for progesterone use:
1 Two or more spontaneous abortions1 Two or more spontaneous abortions
during the first trimester in theduring the first trimester in the
patient’s case history (recurrentpatient’s case history (recurrent
miscarriage).miscarriage).
2 Lutein phase insufficiency confirmed2 Lutein phase insufficiency confirmed
before pregnancy.before pregnancy.
3 Cured infertility.3 Cured infertility.
4 Pregnancy as a result of implementation4 Pregnancy as a result of implementation
of supporting reproductiveof supporting reproductive
technologies.technologies.
23. 2323
Table 4.Table 4. Treatment efficiencyTreatment efficiency
monitoring.monitoring.
MethodMethod Application modeApplication mode
Dynamics monitoring of clinicalDynamics monitoring of clinical
symptoms change.symptoms change.
Twice daily.Twice daily.
Estimation of the patient’s hormonalEstimation of the patient’s hormonal
status using one or several methodsstatus using one or several methods
stated below:stated below:
- determination of serum HCG level in- determination of serum HCG level in
dynamics; - determination of serumdynamics; - determination of serum
progesterone level in dynamics;progesterone level in dynamics;
- hormonal colpocytology;- hormonal colpocytology;
- basal temperature measurement until- basal temperature measurement until
12 weeks of gestation.12 weeks of gestation.
In the term of gestation before 8In the term of gestation before 8
weeks – every 48 hours, after 8weeks – every 48 hours, after 8
weeks – once weekly.weeks – once weekly.
Once weekly, until symptoms stop.Once weekly, until symptoms stop.
Once weekly.Once weekly.
During the course of treatment.During the course of treatment.
USUS Is applied to confirm theIs applied to confirm the
progressing pregnancy.progressing pregnancy.
24. 2424
Abortion in progress.Abortion in progress.
Examination for making the diagnosis.Examination for making the diagnosis.
Speculum examination.Speculum examination.
1 The cervix is shortened, the external1 The cervix is shortened, the external
orifice of the uterus is open.orifice of the uterus is open.
2 Profuse bloody discharge.2 Profuse bloody discharge.
3 Parts of gestational sac present in the3 Parts of gestational sac present in the
cervical canal.cervical canal.
4 Amniotic fluid leakage (absent in the early4 Amniotic fluid leakage (absent in the early
terms of gestation).terms of gestation).
25. 2525
Bimanual examination toBimanual examination to
determine:determine:
- uterine tone;- uterine tone;
- size of uterus;- size of uterus;
- rate of cervical canal opening.- rate of cervical canal opening.
26. 2626
US as needed forUS as needed for
visualization of placentalvisualization of placental
detachment (after 12detachment (after 12
weeks gestation),weeks gestation),
gestational sac (before 12gestational sac (before 12
weeks gestation).weeks gestation).
27. 2727
Abortion in progressAbortion in progress
management approach.management approach.
Term of gestation less than 16 weeks.Term of gestation less than 16 weeks.
Emergency vacuum aspiration orEmergency vacuum aspiration or
curettage of uterine cavity walls iscurettage of uterine cavity walls is
performed with adequate anesthesia.performed with adequate anesthesia.
! It is essential to conduct a! It is essential to conduct a
pathohistological study of aborted tissues.pathohistological study of aborted tissues.
28. 2828
Term of gestation more than 16Term of gestation more than 16
weeks.weeks.
Vacuum aspiration or curettage ofVacuum aspiration or curettage of
uterine cavity walls is performed afteruterine cavity walls is performed after
spontaneous expulsion of gestationalspontaneous expulsion of gestational
sac.sac.
For prevention of endometritisFor prevention of endometritis
antibiotic therapy is prescribed.antibiotic therapy is prescribed.
29. 2929
In cases of bleeding after the expulsion ofIn cases of bleeding after the expulsion of
gestational sac or during the curettage,gestational sac or during the curettage,
uterotonics are used to stimulateuterotonics are used to stimulate
contractive function of the uterus:contractive function of the uterus:
- oxytocin 10 units i.m. or i.v. by drop- oxytocin 10 units i.m. or i.v. by drop
infusion for 500 ml 0,9% NaCl;infusion for 500 ml 0,9% NaCl;
- ergometrin 0,2 mg i.m. or i.v.;- ergometrin 0,2 mg i.m. or i.v.;
- misoprostol 800 mg per rectum.- misoprostol 800 mg per rectum.
30. 3030
Medical method of uterineMedical method of uterine
contents evacuation.contents evacuation.
This non-surgical abortionThis non-surgical abortion
method may be used when themethod may be used when the
patient refuses from surgicalpatient refuses from surgical
hemostasis and generalhemostasis and general
anesthesia.anesthesia.
31. 3131
Necessary conditions forNecessary conditions for
performing medical hemostasis.performing medical hemostasis.
1 Provided incomplete abortion in the first1 Provided incomplete abortion in the first
trimester of gestation has beentrimester of gestation has been
confirmed.confirmed.
2 No absolute indications for surgical2 No absolute indications for surgical
evacuation have been established.evacuation have been established.
3 The patient has agreed to be hospitalized3 The patient has agreed to be hospitalized
in a medical establishment within a medical establishment with
emergency healthcare facilities availableemergency healthcare facilities available
24 hours a day.24 hours a day.
33. 3333
Cases when surgical evacuationCases when surgical evacuation
is required:is required:
- beginning of profuse bleeding;- beginning of profuse bleeding;
- presence of infection symptoms;- presence of infection symptoms;
- if evacuation of uterine contents does not- if evacuation of uterine contents does not
start within 8 hours after mesoprostol wasstart within 8 hours after mesoprostol was
administered;administered;
- if US examination reveals remaining fetal- if US examination reveals remaining fetal
membranes in the uterine cavity after 7 –membranes in the uterine cavity after 7 –
10 days.10 days.
34. 3434
Complete abortion managementComplete abortion management
approach.approach.
It is not required to perform instrumentalIt is not required to perform instrumental
revision of the uterus provided the patientrevision of the uterus provided the patient
has no complaints, there is no bleeding,has no complaints, there is no bleeding,
and the US examination does not showand the US examination does not show
tissues in the uterine cavity.tissues in the uterine cavity.
Control US examination is done after 1Control US examination is done after 1
week.week.
35. 3535
Cervical incompetence (CI).Cervical incompetence (CI).
CI –unrelated to uterine contractive activityCI –unrelated to uterine contractive activity
spontaneous effacement and dilatation ofspontaneous effacement and dilatation of
the cervix which causes miscarriage (morethe cervix which causes miscarriage (more
frequently in the second trimester).frequently in the second trimester).
Cervical incompetence is normallyCervical incompetence is normally
managed by cervical cerclage, which ismanaged by cervical cerclage, which is
placing a preventive or therapeutic sutureplacing a preventive or therapeutic suture
on the cervix.on the cervix.
36. 3636
Preconditions for placing aPreconditions for placing a
suture:suture:
- the fetus is alive, no malformations have- the fetus is alive, no malformations have
been detected;been detected;
- gestational sac is intact;- gestational sac is intact;
- there are no signs of chorionamnionitis;- there are no signs of chorionamnionitis;
- no uterine contractions or bleeding are- no uterine contractions or bleeding are
observed;observed;
- first or second degree of vaginal- first or second degree of vaginal
cleanness.cleanness.
42. 4242
Reproductive system rehabilitationReproductive system rehabilitation
after a spontaneous abortionafter a spontaneous abortion..
1 Prevention of infectious-inflammatory diseases,1 Prevention of infectious-inflammatory diseases,
sanitization of chronic inflammation areas,sanitization of chronic inflammation areas,
normalization of vaginal biocenosis, diagnostics andnormalization of vaginal biocenosis, diagnostics and
treatment of TORCH-infections.treatment of TORCH-infections.
2 Psychological rehabilitation after the miscarriage.2 Psychological rehabilitation after the miscarriage.
3 Non-specific pre-gravid preparation:3 Non-specific pre-gravid preparation:
- anti-stress therapy;- anti-stress therapy;
- nutrition normalization;- nutrition normalization;
- 3 months before conception: folic acid 400mcg- 3 months before conception: folic acid 400mcg
daily;daily;
- establishing a healthy work-leisure balance;- establishing a healthy work-leisure balance;
- giving-up unhealthy habits.- giving-up unhealthy habits.
4. Genetic consultation.4. Genetic consultation.
43. 4343
Labour diagnostics andLabour diagnostics and
confirmation.confirmation.
The onset of cramp-like pains in the lowerThe onset of cramp-like pains in the lower
abdominal regions; appearance of mucinous-abdominal regions; appearance of mucinous-
bloody or watery discharge from genital tract.bloody or watery discharge from genital tract.
Every 10 minutes contractions 15-20 secondsEvery 10 minutes contractions 15-20 seconds
long are registered.long are registered.
The form and location of the cervix changes –The form and location of the cervix changes –
the cervix is shortened and smoothed. Cervicalthe cervix is shortened and smoothed. Cervical
dilatation.dilatation.
Gradual descent of the presenting part of theGradual descent of the presenting part of the
fetus into pelvis minor.fetus into pelvis minor.
44. 4444
Tocolytic therapy.Tocolytic therapy.
Tocolytic therapy is administered before 34 weeksTocolytic therapy is administered before 34 weeks
gestation, in cases when the cervix is less that 3cmgestation, in cases when the cervix is less that 3cm
dilated; there is no amnionitis, preeclampsia or bleeding;dilated; there is no amnionitis, preeclampsia or bleeding;
and the fetus condition is satisfactory.and the fetus condition is satisfactory.
Tocolytic therapy is prescribed during the period of 48Tocolytic therapy is prescribed during the period of 48
hours, necessary for performing antenatal preventivehours, necessary for performing antenatal preventive
procedures against respiratory distress syndrome (RDS)procedures against respiratory distress syndrome (RDS)
with glucocorticoids.with glucocorticoids.
Nifedipin 10 mg sublingually.Nifedipin 10 mg sublingually.
Beta-mimetics (ginepral, ritodrin).Beta-mimetics (ginepral, ritodrin).
2 hours after the start of the tocolytic therapy the2 hours after the start of the tocolytic therapy the
diagnosis of premature labour is confirmed. If thediagnosis of premature labour is confirmed. If the
premature labour progresses – the tocolytic therapy ispremature labour progresses – the tocolytic therapy is
cancelled.cancelled.
45. 4545
Fetal RDS prevention procedures areFetal RDS prevention procedures are
performed from 24th to 34th week ofperformed from 24th to 34th week of
gestation:gestation:
i.m. dexametasone 6 mg every 12 hours,i.m. dexametasone 6 mg every 12 hours,
24 mg for the course of treatment.24 mg for the course of treatment.
When signs of infection are present,When signs of infection are present,
intranatal antibacterial therapy isintranatal antibacterial therapy is
prescribed.prescribed.
46. 4646
Peculiarities of the first laborPeculiarities of the first labor
stage management.stage management.
Fetal condition evaluation:Fetal condition evaluation:
- auscultation of the fetus (every 30- auscultation of the fetus (every 30
minutes during the latent phase, every 15minutes during the latent phase, every 15
minutes during the active phase);minutes during the active phase);
- cardiotocography.- cardiotocography.
47. 4747
In order to achieve reliable auscultationIn order to achieve reliable auscultation
results the following methods are used:results the following methods are used:
- the patient is placed in lateroposition;- the patient is placed in lateroposition;
- the auscultation is started after the end of- the auscultation is started after the end of
the most intensive contraction phase;the most intensive contraction phase;
- the auscultation is performed during at- the auscultation is performed during at
least 60 seconds.least 60 seconds.
If the gestational sac is ruptured the surgeonIf the gestational sac is ruptured the surgeon
should be alerted to the color and amountshould be alerted to the color and amount
of amniotic fluid.of amniotic fluid.
48. 4848
Evaluation of maternal condition:Evaluation of maternal condition:
- body temperature measurement every 4- body temperature measurement every 4
hours;hours;
- pulse rate measurement every 2 hours;- pulse rate measurement every 2 hours;
- arterial pressure measurement every 2- arterial pressure measurement every 2
hours;hours;
- urinary output measurement every 4- urinary output measurement every 4
hours.hours.
49. 4949
Labour progressing evaluation:Labour progressing evaluation:
- frequency and duration of- frequency and duration of
contractions;contractions;
- cervical opening rate;- cervical opening rate;
- fetal head descent level.- fetal head descent level.
50. 5050
Assistance during labor.Assistance during labor.
1 Individual psychological support from the1 Individual psychological support from the
patient’s husband, relatives, medicalpatient’s husband, relatives, medical
staff.staff.
2 Keeping the patient clean.2 Keeping the patient clean.
3 Ensuring that the patient‘s mobility.3 Ensuring that the patient‘s mobility.
4 Assisting the patient with food and drink4 Assisting the patient with food and drink
intake.intake.
5 Labor pain relief at the patient’s request5 Labor pain relief at the patient’s request
(narcotic analgetics are not used).(narcotic analgetics are not used).
51. 5151
Care and assistance during theCare and assistance during the
second labor stage.second labor stage.
Auscultation of the fetus is performed every 5Auscultation of the fetus is performed every 5
minutes.minutes.
Arterial pressure and pulse of the patient areArterial pressure and pulse of the patient are
measured every 15 minutes.measured every 15 minutes.
Obstetric care methods are chosen inObstetric care methods are chosen in
accordance with the phase requirements of theaccordance with the phase requirements of the
second labor stage.second labor stage.
The patient is either in upright or supineThe patient is either in upright or supine
position for labor management.position for labor management.
Episioperineotomy and pudendal anesthesiaEpisioperineotomy and pudendal anesthesia
are not performed.are not performed.
52. 5252
Active management of the thirdActive management of the third
labor stage.labor stage.
Introduction of uterotonics.Introduction of uterotonics.
Expulsion of placenta by controlled umbilicalExpulsion of placenta by controlled umbilical
cord traction.cord traction.
Uterine cavity massage via abdominal wallUterine cavity massage via abdominal wall
after placenta expulsion every 15 minutesafter placenta expulsion every 15 minutes
during 2 hours.during 2 hours.
Parturient canal examination after the labor isParturient canal examination after the labor is
performed when bleeding is present, afterperformed when bleeding is present, after
operative delivery or home delivery.operative delivery or home delivery.
Cold compress on the lower abdomen in theCold compress on the lower abdomen in the
early postpartum period is not applied.early postpartum period is not applied.
