spontaneous abortion
Introduction
Introduction to spontaneous abortion Spontaneousabortion refers to the pregnancy that terminates spontaneously before 28 weeks, and the weight of the fetus is less than 1000g. This definition is based on the abortion period set by the World Health Organization in 1966. At present, there are many controversies about the duration of abortion. Some countries limit the period of abortion to 25 weeks or even 20 weeks. Because in the developed countries, the gestational age is more than 20 weeks, and the newborns weighing 600-700g survive because of adequate treatment. opportunity. However, according to the actual situation in China, the abortion period is still limited to 28 weeks ago. Clinically, abortion occurs before 12 weeks of gestation, which is called early abortion; in the latter 12 weeks, the latter is called late abortion. Natural abortion is a common gynecological disease. If it is not treated in time, it may leave genital inflammation, injury, or major bleeding. Endangering the health of pregnant women and even threatening their lives; in addition, spontaneous abortion is also easily confused with certain gynecological diseases, and attention should be paid to identification. basic knowledge Probability ratio: 2% of women in childbearing age Susceptible population: pregnant women Mode of infection: non-infectious Complications: pelvic inflammatory disease, bloating, septic shock
Cause
Cause of spontaneous abortion
Embryo chromosomal abnormalities (20%):
Chromosomal abnormalities are the most common cause of spontaneous abortion. Domestic and foreign literature reports that 46% to 54% of spontaneous abortions are associated with embryonic chromosomal abnormalities. According to Warburton et al., the earlier the abortion occurs, the higher the frequency of embryonic chromosomal abnormalities. Abnormalities include quantitative anomalies and structural anomalies. In the number of abnormalities, the stained trisomy was ranked first, accounting for 52%. Except for the No. 1 stained trisomy, no trisomy were found, and all three tribes were found, among which 13,16,18 Chromosome 21 and 22 are the most common, 16 trisomy is about 1/3; the second is 45, X monomer, about 19%, is the more common chromosomal abnormality after the trisomy, if it can survive, Turner syndrome is formed after full-term delivery. Triploids often coexist with vesicular degeneration of the placenta. Fetuses with incomplete vesicular blocks can develop into triploid or chromosome III, with abortion earlier. A small number of survivors, continued to develop with multiple malformations, no live infants, very few tetraploid live infants, most of the very early abortion, chromosomal abnormal structural abnormalities are mainly chromosomal translocation (3.8%), chimera (1.5%) ), etc., chromosome inversion, deletion and overlap It reported.
From an epidemiological point of view, the incidence of abortion increases with the age of women. Therefore, it is believed that embryonic chromosomal abnormalities may be related to the age of pregnant women, but studies have shown that in addition to the older age of the 21 trisomy and the mother. The other three bodies have nothing to do with the age of the mother.
Maternal factor (25%):
(1) chromosomal abnormalities in couples: As early as 1960, Schmiel et al. had found that habitual abortion was associated with chromosomal abnormalities in couples. Domestic and foreign literature reported that the frequency of chromosomal abnormalities in couples with habitual abortion was 3.2%, of which chromosomes were more common. Mutual translocation, accounting for 2%, Robertsonian translocation accounted for 0.6%, domestic data showed that the frequency of chromosomal abnormalities in recurrent abortion couples was 2.7%.
(2) Endocrine factors:
1 luteal dysfunction: luteal phase progesterone peak is less than 9ng / ml, or endometrial biopsy and menstrual time synchronization for more than 2 days can be diagnosed as luteal dysfunction, high concentration of progesterone can prevent uterine contraction, so that the uterus is maintained Relatively static state; insufficient progesterone secretion can cause poor decidual reaction in pregnancy, affecting implantation and development of pregnant eggs, leading to miscarriage. There are two ways to progesterone in pregnancy: one is produced by ovarian corpus luteum, and the other is placental trophoblast Secretion, 6-8 weeks after pregnancy, the progesterone production of ovarian corpus luteum gradually decreases, and then the progesterone replacement by the placenta, if the two are misaligned, prone to miscarriage, progesterone secretion is closely related to abortion, 23 in habitual abortion Chive dysfunction is present in % to 60% of cases.
2 polycystic ovary: It has been found that the incidence of polycystic ovary in habitual abortion can be as high as 58%, and 56% of patients have high secretion of LH. It is believed that high concentration of LH in polycystic ovary may lead to second egg cell. The secondary meiosis is completed prematurely, affecting the process of fertilization and implantation.
3 hyperprolactinemia: high levels of prolactin can directly inhibit the proliferation and function of corpus luteum cells. The main clinical manifestations of hyperprolactinemia are amenorrhea and lactation. When prolactin is at the upper limit of normal, it can be characterized by luteal function. Not complete.
4 Diabetes: A prospective study by Milis et al. showed that patients with diabetes who had good glycemic control during early pregnancy (within 21 days) had no difference in the incidence of miscarriage compared with non-diabetic groups, but the incidence of miscarriage in patients with poor glycemic control could be as high as 15% to 30%. In addition, hyperglycemia in early pregnancy may be a risk factor for embryo malformation.
5 Thyroid function: In the past, hypothyroidism or hyperthyroidism was thought to be related to abortion, but this view has been controversial.
Anatomical factors of reproductive organs (20%):
(1) uterine malformation: uterine malformations such as single-horned uterus, double-horned uterus, double uterus, uterine mediastinum, etc., can affect uterine blood supply and intrauterine environment caused by miscarriage.
(2) Asherman syndrome: intrauterine adhesions and fibrosis caused by intrauterine trauma (such as excessive curettage), infection or placental residue, hysteroscopic endometrial resection or submucosal myomectomy can also cause Intrauterine adhesions, endometrial insufficiency can affect embryo implantation, leading to recurrent miscarriage, hysteroscopy contributes to the diagnosis of intrinsic, Romer et al used hysteroscopy to examine a group of cases, found incomplete abortion and after expired abortion The incidence of intrauterine adhesions is about 20%, and recurrent abortion cases are as high as 50%.
(3) Cervical dysfunction: Cervical dysfunction is the main cause of middle and late abortion. Cervical dysfunction is manifested as anatomical shortness of the cervical canal or relaxation of the internal cervix. Due to anatomical defects, along with the progress of pregnancy Uterine enlargement, increased intrauterine pressure, most patients in the middle and late pregnancy, painless cervical tube regression, uterine dilatation, amniotic sac prominent, membrane rupture, eventually miscarriage, cervical dysfunction mainly due to local cervical trauma (Childbirth, surgical midwifery, cesarean section, cervical conization, Manchester surgery, etc.), congenital cervical dysplasia is less common; in addition, exposure to diethylstilbestrol during embryonic period can also cause cervical dysplasia.
(4) Others: Uterine tumors can affect the uterine environment and cause miscarriage.
Reproductive tract infections (15%):
Some chronic infections of the reproductive tract are considered to be one of the causes of early abortion. Pathogens that cause recurrent miscarriage often persist in the genital tract and the mother rarely produces symptoms, and this pathogen can directly or indirectly cause embryonic death, and the reproductive tract is retrograde. Infection usually occurs before 12 weeks of gestation. During this period, the placenta merges with the aponeurosis to form a mechanical barrier. As the pregnancy progresses, the anti-infective capacity of amniotic fluid increases and the chance of infection decreases.
(1) Bacterial infection: Brucella and campylobacter infection can cause abortion of animals (bovine, pig, sheep, etc.), but it is not certain in humans. Some people think that Listeria monocytogens ) has a certain relationship with related abortion, but lacks definite evidence.
(2) Chlamydia trachomatis: The literature reports that the infection rate of Chlamydia trachomatis during pregnancy is 3% to 30%, but whether it directly leads to abortion is inconclusive.
(3) Mycoplasma: The positive rate of mycoplasma in the cervix and flow products of abortion patients is high, and serologically support mycoplasma hominis and ureaplasma urealyticlum are related to abortion.
(4) Toxoplasma: Abortion caused by Toxoplasma infection is sporadic, and the relationship with habitual abortion has not been fully proved.
(5) viral infection: cytomegalovirus (cytomegalovirus) can affect the fetus through the placenta, causing cardiovascular system and nervous system malformation, death or miscarriage, the incidence of herpes simplex infection in the first half of pregnancy can be as high as 70%, even No abortion, but also easy to affect the fetus, neonatal, early pregnancy, rubella virus infection (rubella virus) infected people with a high incidence of abortion, human immunodeficiency virus (HIV) infection and abortion are closely related, Temmerman et al reported, HIV-1 antibody positive is an independent factor associated with miscarriage.
Immunity factor (10%):
Abortion caused by immune factors, especially recurrent abortion, habitual abortion can be divided into two types, namely autoimmune type and allotype, autoimmune type can usually detect various autoantibodies from patients, mainly antiphospholipid antibodies Allogeneic patients are screened for etiology and exclude common causes, so it is also called unexplained habitual abortion; this is mainly related to poor physiological immune response during pregnancy, lack of immunosuppressive factors or blocking factors, and final embryos. Suffering from immunological damage, leading to miscarriage.
(1) Autoimmune type: Autoimmune habitual abortion is mainly related to antiphospholipide antibody in patients. Some patients may be accompanied by thrombocytopenia and thromboembolism. These patients may be called early antiphospholipid antibodies. Antiphospholipide antibody syndrome, in addition, autoimmune habitual abortion is also associated with other autoantibodies.
Antiphospholipid antibody component: Antiphospholipid antibody is an autoimmune antibody, including lupus anticoagulant factor (LAC), anticardiolipin antibody (ACL), antiphosphatidylserine antibody (APSA), antiphosphatidylinositol antibody (APIA), antiphospholipid ethanolamine antibody (APEA) and antiphosphatidic acid antibody (APAA), etc., can detect several antibodies simultaneously in various autoimmune diseases; among them, anti-cardiolipin antibody and lupus anticoagulant factor are the most representative Sexual and clinical significance, there are three types of anti-cardiolipin antibodies: IgG, IgA, IgM; among them, IgG is most clinically meaningful.
(2) Immune type: Modern reproductive immunology believes that pregnancy is a successful semi-allogous transplantation process. Pregnant women develop a series of adaptive changes due to the autoimmune system, thus showing immune tolerance to intrauterine embryo transfer. No rejection occurs, allowing pregnancy to continue.
Susceptible genes or monomers: In recent years, some scholars believe that there may be susceptibility genes or monomers in patients with habitual abortion. According to genetic theory, there are clinical susceptibility genes or monomers in the human genome. Moreover, this is easy. The gene or monomer may be present in the HLA complex or other genes closely linked to it. The mother containing the abortive susceptibility gene or monomer is low in response to the embryonic antigen and cannot stimulate the maternal immune system to produce a blocking factor. There are differences in the location or location of susceptibility genes or monomers, which may be related to the racial specificity of HLA.
(3) Local uterine immunity: The current study shows that there is a significant adaptive response in the uterine decidua during normal pregnancy, and NK cell subpopulations undergo phenotypic conversion, that is, from CD56 CD16-type (killing type) to CD56 CD16. Type (secretory)-based, secretory NK cells can secrete some cytokines, such as TGF-, etc. These cytokines exert immunological or immunosuppressive effects on the local uterus, and we found that habitual abortion The patient's uterine local physiological immune response is insufficient, and NK cells are still mainly killing type, which may be directly related to the pathogenesis of the disease.
Other factors (8%):
(1) Chronic wasting disease: Tuberculosis and malignant tumors often lead to early abortion and threaten the life of pregnant women. High fever can cause uterine contraction; anemia and heart disease can cause fetal placental unit hypoxia; chronic nephritis, hypertension can cause placenta Infarction.
(2) Malnutrition: Severe malnutrition can directly lead to miscarriage, and now more emphasis on the balance of various nutrients, such as vitamin E deficiency can also cause miscarriage.
(3) Mental and psychological factors: Anxiety, nervousness, intimidation and other serious mental stimuli can lead to miscarriage. Recently, it has also been found that noise and vibration have certain effects on human reproduction.
(4) Smoking, drinking: In recent years, the number of women of childbearing age who smoke, drink, or even take drugs has increased; these factors are high risk factors for miscarriage. Drinking too much coffee during pregnancy also increases the risk of miscarriage. There is no clear evidence for this. The use of contraceptives is associated with abortion. However, it has been reported that intrauterine contraceptives fail to increase the incidence of infectious abortion.
(5) Environmentally toxic substances:
1 Mercury: Mercury can be in the form of metallic mercury, inorganic mercury and organic mercury compounds. The teratogenic effect of mercury has been confirmed in animal experiments. Malformations are characterized by dysplasia and eye defects. In addition, it can be expressed as cleft lip and palate, ribs. Fusion and maxillofacial deformity, a survey of occupational exposure to mercury found that the incidence of spontaneous abortion, stillbirth and congenital defects was 1 times higher than that of the control group. The mechanism of mercury teratogenicity and abortion may be related to genetic material damage. Mercury can bind to nuclear proteins to cause chromosomal changes, and can increase the number of free radicals in the cells to cause damage to DNA molecules, and can also cause damage to the cell spindle and affect the normal division of cells.
2 Cadmium: Cadmium has obvious adverse effects on the development of offspring. Exposure to cadmium during pregnancy can cause embryo absorption, death and various malformations. The most common sites of deformity are brain, limbs and bones, and cadmium on embryos. The mechanism of toxic action is related to cadmium inhibiting cell growth and division, mainly inhibiting the synthesis of DNA and protein. It can block the incorporation of thymidine into DNA, reduce DNA synthesis, and may inhibit thymidine activating enzyme. The result of the activity.
3 Lead: Lead can affect the fetus through the placenta. A large number of animal experiments have shown that lead can cause abnormalities in the fetal litter of experimental animals, mainly neurological defects. The teratogenic effect of lead on humans is also obvious. Exposure of pregnant women to excessive lead can cause Fetal abortion and death can also lead to an increase in the incidence of birth defects in the offspring. The teratogenic mechanism of lead may be related to the following effects: damage to germ cell DNA and chromosomes; damage to the spindle of the cell, affecting cell mitosis; Into the mitochondria affects the tricarboxylic acid cycle; lead causes excitement in the uterine muscles, leading to miscarriage.
4 Arsenic: Animal experiments show that arsenic deficiency can affect the growth and reproduction of animals. High concentrations of arsenic have teratogenic effects. The types of teratogenesis include central nervous system defects, eye defects, cleft lip and palate fusion, and inorganic arsenic can make breast milk. Increased arsenic content can also cause fetal malformation and miscarriage through the placenta. The mechanism of teratogenicity and abortion is to interfere with the development of visceral yolk sac.
5 chloroprene: causes embryo death.
6 Vinyl Chloride: Causes an increase in the incidence of miscarriage and malformation.
Dichloro-diphenyl-trichloro-ethane (DDT): can increase the incidence of spontaneous abortion and low birth weight infants.
The cause of abortion is summarized in Figure 1.
Pathogenesis
Under normal circumstances, various negatively charged phospholipids are located in the inner layer of the lipid bilayer of the cell membrane and are not recognized by the immune system; once exposed to the body's immune system, various antiphospholipid antibodies can be produced, and the antiphospholipid antibody is not only one Strong clotting active substances, activate platelets and promote blood clotting, leading to platelet aggregation and thrombosis; at the same time, it can directly cause vascular endothelial cell damage, aggravate thrombosis, local thromboembolism in placental circulation, placental infarction, fetal death, resulting in Abortion, recent studies have also found that antiphospholipid antibodies may directly bind to trophoblast cells, thereby inhibiting trophoblast function and affecting the placental implantation process.
It is currently known that trophoblastic HLA-G antigen expression may play an important role in this immunoregulatory process. In addition, in the maternal serum of normal pregnancy, one or more can inhibit immune recognition and immune response. Blocking factors, also known as blocking antibodies, and immunosuppressive factors, are lacking in habitual abortion patients, thus causing the embryo to be rejected by the mother's immune attack.
1. Blocking factor: The blocking factor is a group of IgG-type anti-spouse lymphocyte cytotoxic antibodies. It is generally believed that the blocking factor can directly act on the maternal lymphocytes and bind to the surface specific antigen of the trophoblast cells, thereby blocking the mother and child. Interim immunological recognition and immune response, blocking the cytotoxic effect of maternal lymphocytes on trophoblast cells, and suggesting that blocking factor may be an anti-idiotypic antibody directed against T lymphocyte or B lymphocyte surface-specific antigen receptors ( BCR/TCR) prevents maternal lymphocytes from reacting with embryonic target cells, and in vitro, blocking factors can inhibit mixed lymphocyte reaction (MLR).
2. HLA antigen: The relationship between homologous immunological habitual abortion and HLA antigen compatibility has been controversial for decades. In recent years, it has been found that HLA-G antigen may play an important role in the pathogenesis of habitual abortion. In addition, some progress has been made in the study of susceptibility genes or monomers for habitual abortion.
HLA-G: As early as the 1970s, some scholars suggested that habitual abortion may be related to the compatibility of couple HLA antigens. It is believed that HLA antigens are incompatible between couples and mothers during normal pregnancy. Embryos The father-derived HLA antigen can stimulate the maternal immune system and produce a blocking factor. The study of HLA antigen compatibility mainly involves the A, B sites of HLA-I antigen molecules and the DR of HLA-II antigen molecules. DQ locus, however, after more than 20 years of research, it is still difficult to determine the exact relationship between HLA antigen compatibility and habitual abortion. In recent years, with the improvement of molecular biology detection, people have found more habitual abortion. There is no need for increased HLA compatibility between the couple or the mother, but it is found that the expression of HLA-G antigen may be involved in the onset of habitual abortion.
It is generally believed that trophoblasts do not express classical HLA class I antigen molecules. In recent years, most scholars have demonstrated that trophoblast cells can express a class of non-classical HLA-I antigens that are specific for W6/32 and 2m antibodies. Binding, its molecular weight is low, this HLA-I antigen is now named HLA-G antigen, experimentally observed that the level of HLA-G expression in trophoblasts gradually decreases with the progress of pregnancy, indicating HLA-G gene The expression is regulated by extraembryonic tissues. It is currently believed that the main role of trophoblast cells in expressing HLA-G antigen is to regulate the local immune response of the uteroplacenta. HLA-G can induce an inhibitory immune response, which is protective for the fetus. The role of the maternal immune system can inhibit the fetal placenta attack, although some scholars have suggested that habitual abortion may be related to abnormal expression of trophoblastic HLA-G; however, the exact mechanism is still unclear and needs further study.
Prevention
Natural abortion prevention
Abortion brings both physical and mental damage to women. Many women who have experienced miscarriage are worried about this. They worry about whether they will have a miscarriage when they are pregnant again. The question they are very concerned about is "Can abortion be prevented?" In fact, the vast majority Abortion can be prevented. To prevent the occurrence of abortion, pay attention to the following aspects:
1. The age of pregnancy should be appropriate: early marriage and early childbirth can cause miscarriage due to immature body development. When the age is too large during pregnancy, the reproductive function will decline, and the chromosome will be abruptly caused by abortion. The best reproductive age is 23 to 28 years old. .
2. If there is no intention to become pregnant, contraceptive measures should be taken to avoid damage to the uterus caused by induced abortion after unintended pregnancy.
3. Do not rush to re-pregnancy after abortion, should be separated by more than half a year, so that the uterus is fully restored, the body's blood can be filled and then pregnant, otherwise the body has not fully recovered, pregnancy is likely to cause recurrence of abortion, the speed is Not up.
4. Before going to the hospital for medical examination, especially those who have had a history of abortion in the past, should do a comprehensive examination. If there is a certain disease, first treat it, wait until the disease is cured and then get pregnant. Some uterine malformations can be operated. Treatment, correction of deformity; rubella virus, Toxoplasma gondii, herpes simplex infection, should be treated first, until the pregnancy is negative after pregnancy; there are luteal dysfunction, hyperthyroidism, severe anemia, diabetes and other diseases should also control the disease first Plan for pregnancy; cervical laceration should first be done with cervical canal repair; abortion caused by relaxation of the internal cervix should be performed at 14 to 16 weeks of gestation for cervix cervix to prevent miscarriage.
5. Avoid contact with toxic substances such as mercury, lead, cadmium, DDT, radiation, etc. after pregnancy. If the working environment requires long-term exposure to these substances, you can apply for replacement work; avoid strenuous exercise, climb, slip, stand too long, wear High heels, avoid rough sex life; don't smoke or drink; eat less or not fry, spicy and other irritating foods and kelp, mung beans, glutinous rice and other cold foods; maintain a good attitude, avoid nervousness, anxiety, Depressive, excessive excitement and other negative emotional stimuli, try not to read too stimulating books, TV, movies and drama; at the same time, family members should give pregnant women full understanding, support, encouragement and enthusiasm to help pregnant women maintain spiritual peace and happiness. .
6. Avoid contact with cats, dogs, birds and other pets before and after pregnancy to avoid infection with Toxoplasma gondii; avoid unclean sexual intercourse and infection with mycoplasma, chlamydia, herpes simplex virus, gonorrhea, syphilis, etc.
Complication
Spontaneous abortion Complications, pelvic inflammatory disease, bloating, septic shock
1. Major bleeding: The most common complication of inevitable abortion or incomplete abortion, severe hemorrhage can lead to hemorrhagic shock.
2. Infection: All types of abortion can be combined with infection, but more incomplete abortion, often combined with pelvic inflammatory disease, bloating, systemic infection and septic shock.
Symptom
Symptoms of spontaneous abortion Common symptoms Lower abdominal pain Vaginal bleeding Menstrual uterus Small complete abortion Threat abortion Abdominal pain Habitual abortion scattered pulse echo shadow
Symptom
(1) Menopause: Most patients with abortion have a significant history of menopause. According to the length of menopause, abortion can be divided into early abortion and late abortion.
(2) vaginal bleeding: abortion within 3 months of pregnancy, villus and decidua separation, sinusoidal opening, so early abortion have vaginal bleeding, and bleeding is often more, late abortion, placenta has formed, abortion The process is similar to premature delivery, and the placenta is discharged after the delivery of the fetus, and the amount of bleeding is generally small.
(3) Abdominal pain: early abortion begins after vaginal bleeding, there is blood in the uterine cavity, especially blood clots, stimulating uterine contraction, persistent lower abdominal pain, late abortion, first paroxysmal uterine contraction, then fetal placenta discharge, so in the vagina There is abdominal pain before bleeding.
2. Clinical classification
According to different clinical development processes, clinical can be divided into 7 types.
(1) Threatened abortion: refers to the pregnancy remains in the uterine cavity, but the clinical symptoms of abortion, common in early pregnancy, vaginal bleeding is not much, is bright red, if accumulated in the vagina for a long time, then Brown, mostly manifested as drip, can last for several days or weeks, symptoms of abdominal pain may be optional, to a lesser extent, can continue pregnancy after treatment of uterine, gynecological examination: cervix closure, amniotic sac is not broken, uterine body size Consistent with the menopause month, it is worth pointing out that pregnant women with a history of threatened abortion are often associated with poor perinatal outcomes, such as premature birth, low birth weight, and perinatal death.
(2) inevitable abortion (inevitable abortion): is the continuation of threatened abortion, pregnancy is difficult to sustain, there is a clinical process of miscarriage, vaginal bleeding for a longer time, more bleeding, and blood clots, paroxysmal lower abdominal pain, or Amniotic fluid outflow, gynecological examination: the cervix is enlarged, the amniotic sac is protruding or has been ruptured, and the embryonic tissue is blocked in the cervical canal, and even exposed to the external cervix.
(3) Incomplete abortion: During the abortion, the fetus and part of the placenta are excreted. Some placenta or the whole placenta remains in the uterine cavity, which is called incomplete abortion. Abortion occurs before 8 weeks of pregnancy, and the fetal placenta component can be discharged at the same time. At 8 to 12 weeks of gestation, the placenta structure has formed and is closely connected to the decidua, and the flow product is not easily peeled off from the uterine wall. Incomplete abortion often occurs. Due to residual embryonic tissue in the uterine cavity, the uterus does not shrink well. As a result, vaginal bleeding is more, and the time is longer, which may cause intrauterine infection. Gynecological examination: The cervix has been dilated, and there are constantly bloody spills. Sometimes the embryonic tissue is blocked in the cervix or some embryonic tissue is excreted in the vagina. The uterus is smaller than Normal pregnancy days.
(4) Complete abortion: After the threatened abortion and inevitable abortion, the fetal placenta tissue is completely discharged in a short time, vaginal bleeding and abdominal pain stop, often occurs before 8 weeks of gestation, gynecological examination: cervix closure, uterus Close to normal size.
(5) Missed abortion: also known as missed abortion, refers to abortion that has not been naturally discharged after more than 2 months of embryo death. The exact cause of expired abortion is unclear, and may be related to female, progesterone levels and uterine sensitivity. In addition, it is also related to the premature abortion of the threatened abortion. Sometimes the embryo is actually dead, but it also uses progesterone drugs such as progesterone to inhibit uterine contraction, resulting in embryonic retention.
(6) habitual abortion: spontaneous abortion for 3 or more consecutive times is called habitual abortion, and some people refer to recurrent spontaneous abortion for 2 or more consecutive times. The incidence rate is about 1% of the total number of pregnancies, accounting for 15% of the number of spontaneous abortions. In recent years, there have been many studies on habitual abortion, mainly focusing on two aspects. One is the immune pathogenesis and immunity to habitual abortion. The prevention and treatment research, the second is the diagnosis and treatment of cervical dysfunction.
(7) Infected abortion: refers to abortion combined with reproductive system infections, all types of abortion can be concurrent infection, including selective or therapeutic abortion, but incomplete abortion, expired abortion and illegal abortion common.
Examine
Spontaneous abortion check
Chromosomal abnormality
It is mainly based on the karyotype analysis of peripheral blood nucleus of embryonic chromosomes and couples to determine whether the chromosomal abnormality of the embryo is a primordial or maternal chromosomal abnormality.
2. Endocrine function check
Clinically, it is mainly based on the patient's menstrual cycle, basal body temperature, complete sex hormone measurement, endometrial biopsy, thyroid function and blood glucose test to understand whether there is luteal insufficiency or other endocrine diseases. The laboratory diagnosis of luteal insufficiency is: Endometrial biopsy showed endometrial development lags behind the menstrual cycle for 2 days or more.
(1) Progesterone: gestational urinary diol in the luteal phase, the normal value is 6 ~ 22mol / 24h urine, less than the lower limit is luteal insufficiency, the peak of serum gestational diol in the luteal phase is 20.7 ~ 102.4nmol / L, low At 16nmol/L, luteal insufficiency, progesterone levels continued to increase after pregnancy, 7 weeks (76.4 ± 23.7) nmol / L, 8 weeks (89.2 ± 24.6) nmol / L, 9 ~ 12 weeks ( 18.6±40.6)nmol/L, 13~16 weeks is (142.0±4.0) nmol/L. It is worth noting that the individual difference of progesterone determination is large, and the value is also varied at different times every day, so the measured value can only be used as Reference, low progesterone levels are prone to miscarriage. It has been reported that the sensitivity and specificity of single progesterone measurement for predicting intrauterine fetal survival are 88%. Hahlin et al reported that 83% of spontaneous abortion patients have low serum progesterone levels. A progesterone level of less than 31.2 nmol/L indicates that the embryo has died.
(2) HCG: HCG can be measured in maternal blood 8 to 9 days after pregnancy. With the progress of pregnancy, HCG gradually increases. The HCG doubling time in early pregnancy is about 48 hours, and the peak of pregnancy is 8 to 10 weeks. The serum -HCG value is low or decreasing, suggesting that miscarriage may occur. Table 2 shows the relationship between serum -HCG and ultrasound at the time of pregnancy.
(3) Human placental lactogen (HPL): HPL secretion is closely related to placental function. The normal value of serum HPL is 0.02 mg/L at 6-7 weeks of gestation, 0.04 mg/L at 8-9 weeks, and the low level of HPL is often A precursor to abortion.
(4) Cervical mucus: If the smear shows fern-like crystals, it indicates a poor prognosis.
(5) vaginal cytology examination: vaginal smear sees the presence of villus mosaic cells, the incidence of abortion is almost 100%; therefore, this method can predict the outcome of abortion, once the emergence of such cells should be early termination of pregnancy, syncytial cells The characteristics of the smear are: cell size varies, cytoplasmic basophilic, contains a different number of deep-stained nuclei, often surrounded by red blood cells and white blood cells.
(6) Determination of thyroxine and blood glucose: hypothyroidism and hyperthyroidism are prone to abortion. Determination of free T3 and T4 by radionuclide can help determine the thyroid function during pregnancy. The normal fasting blood glucose value is 5.9mmol/L. Glucose tolerance test to rule out diabetes.
3. Infection related inspection
It should include examinations of Toxoplasma gondii (TOXO), cytomegalovirus (CMV), Chlamydia trachomatis (CT), Mycoplasma hominis, and Ureaplasma urealyticum (MH, UU).
4. Immunological examination
(1) autoimmune recurrent miscarriage: patients excluded embryos and couples peripheral blood karyotype, reproductive tract infection, endocrine and reproductive organs anatomy and other abnormal conditions, autoantibody detection is positive, there are often two cases:
1 anti-phospholipid antibody (ACL, LCA) positive;
2 anti-nuclear antibody (ANA) and extractable nuclear antigen antibody (ENA) positive.
(2) Immune type (unexplained) habitual abortion:
1 There were no abnormalities in the screening of etiology by chromosome, anatomy, endocrine and infection.
2 various autoantibodies are negative.
3 blocking antibody deficiency, negative lymphocyte toxicity test (LCT), one-way mixed lymphocyte culture (MLC) + inhibition test showed that the inhibition of proliferation was significantly reduced.
B-ultrasound
At present, it is widely used, the differential diagnosis of abortion and the actual value of determining the type of abortion. Generally, after 5 weeks of pregnancy, the gestational sac aura can be seen in the uterine cavity, which is a circular or elliptical anechoic zone, sometimes due to implantation. A small amount of bleeding, visible ring dark area around the gestational sac, this is the double-ring sign of early pregnancy, after 6 weeks of pregnancy, the germ image can be seen, and the heart tube beats, the carcass activity can be seen at 8 weeks of pregnancy, the gestational sac accounts for about half of the uterine cavity, pregnancy The fetal contour can be seen in 9 weeks. The 10-week gestational sac almost fills the entire uterine cavity. The fetus has a complete morphology at 12 weeks of gestation. Different types of abortions and their ultrasound images also have different characteristics, which can help differential diagnosis.
1. Threatened abortion sonogram features:
1 The size of the uterus is consistent with the month of pregnancy;
2 a small amount of bleeding on the side of the gestational sac is seen in the absence of echo zone;
3 bleeding more uterine cavity has a larger amount of blood, sometimes visible fetal membrane and uterine cavity separation, there is an echo zone behind the membrane;
4 normal 6 weeks after pregnancy can be seen normal heart beat.
2. Inevitable abortion sonogram features:
1 The gestational sac deforms or collapses;
2 The internal opening of the cervix is enlarged, and the embryonic tissue is obstructed in the cervical canal. If the amniotic sac is not broken, the amniotic sac protrudes into the cervical canal or protrudes from the external cervix;
3 heart tube beats have disappeared.
3. Incomplete abortion sonogram features:
1 The uterus is smaller than the normal gestation month;
2 There is no complete gestational sac structure in the uterine cavity, and it is replaced by an irregular light group or a small dark area;
3 heart tube beat disappeared.
4. Complete abortion sonogram features:
1 The size of the uterus is normal or close to normal;
2 uterine emptiness, see a regular uterine line, no irregular light group.
Diagnosis
Spontaneous abortion diagnosis
diagnosis
History
Determine if there is a history of menopause and a history of recurrent miscarriage.
2. Clinical manifestations
Detailed observation of vaginal bleeding and abdominal pain, vaginal secretions, etc., physical examination: whether there is anemia, blood pressure, pulse condition, gynecological examination of the cervix open or not open, cervix and vagina with or without pregnancy products from the palace Excretion, the size of the uterus is consistent with the gestational age.
3. Auxiliary inspection
B-ultrasound can be based on whether there is a gestational sac in the uterus, whether there is fetal heart reflex and fetal movement to determine whether the embryo or fetus survives or exists, can also determine incomplete abortion and missed abortion, -HCG quantification and other hormones such as blood progesterone The determination can help determine the prognosis of threatened abortion.
Differential diagnosis
Tubal pregnancy
(1) Menopause time: Except for the longer period of menopause in the tubal interstitial, the history of menopause is 6-8 weeks, and 20%~30% of patients have no obvious history of menopause. The irregular vaginal bleeding may be mistaken for the last menstrual period. Or because menstruation only expires for a few days, it is not considered to be menopause, and the menstrual period of abortion can be longer.
(2) vaginal bleeding and color: There are many vaginal bleeding in the tubal pregnancy, the color is dark brown, the amount is small, generally does not exceed the amount of menstruation, dripping endless, may be accompanied by decidual tube type or aponeurosis fragments, vaginal bleeding After the lesion is removed, it can be stopped, and the amount of vaginal bleeding during abortion generally increases gradually, starting from a bright red, and if the bleeding time is long, it becomes dark red or brown.
(3) Abdominal pain: Before the abortion or rupture of the tubal pregnancy, it often manifests as a pain or soreness in one side of the lower abdomen. When abortion or rupture occurs, the patient suddenly has a tear in the lower abdomen, often accompanied by nausea and vomiting. Severe cases may have syncope, shock, may be accompanied by frequent intentions and anal bulge discomfort, and abortion abdominal pain is paroxysmal, the lower abdomen is in the middle, ranging from mild fall pain to obvious spastic pain, varying degrees.
(4) Gynecological examination: When the tubal is pregnant, the vagina is full and tender, and the cervix is painful. This is one of the main features of tubal pregnancy. The uterus is slightly larger and softer. When the internal bleeding is frequent, the uterus has a sense of floating, the uterus. One side or the rear can touch the unclear mass of the border, and the tenderness is obvious.
(5) Auxiliary examination: 1 dark red blood coagulation when puncture of the vagina after vaginal puncture can help diagnose tubal pregnancy;
2 urine pregnancy test is positive, but the patient's HCG level is significantly lower than the intrauterine pregnancy;
3B type ultrasonography revealed that the uterus was enlarged but the uterine cavity was emptied, and there was a hypoechoic area next to the uterus, and the germ and the original cardiac tube pulsation were seen, which can be diagnosed as tubal pregnancy;
4 Laparoscopy helps to improve the accuracy of ectopic pregnancy diagnosis.
Hydatidiform mole
(1) Menopause time: Most patients have a history of menopause for 2 to 4 months, with an average of 12 weeks.
(2) vaginal bleeding: hydatidiform moles are characterized by irregular vaginal bleeding, often dark red, the amount of uncertainty, intermittent, during which there may be repeated large bloodshed, most patients with anemia appearance, carefully examined sometimes in the blood flowing out A blister sample can be found to help confirm the diagnosis.
(3) Abdominal pain: When the hydatidiform growth is rapid, the intrauterine hemorrhage causes the uterus to increase rapidly, which can cause paroxysmal pain in the lower abdomen, which can generally be tolerated. The hydatidous hyaline pain of the hydatidiform mole is often accompanied by intermittent bleeding. .
(4) gynecological examination: the uterus is significantly larger than the menopause month, the texture is very soft, the uterus, such as pregnancy 5 months old, can not touch the carcass, can not hear the fetal heart, can not feel fetal movement, should be suspected of hydatidiform mole.
(5) Auxiliary inspection:
1 Chorionic gonadotropin (HCG) determination: In normal pregnancy, the trophoblasts begin to secrete HCG on the 6th day after implantation of the fertilized egg. As the pregnancy progresses, the serum HCG value gradually increases, reaching a peak at 8 to 10 weeks of gestation. Serum HCG values gradually decrease, but during hydatidiform mole, trophoblasts are highly proliferating, producing a large amount of HCG. The serum HCG value is usually higher than the normal pregnancy value of the corresponding gestational age, and HCG continues to rise after 12 weeks of menopause. Can be used as an auxiliary diagnosis.
2B type ultrasound examination: it is an important auxiliary examination method for diagnosing hydatidiform mole. It shows that the uterus is significantly larger than the menopause month, no gestational sac, no fetal heartbeat motility, and the uterine cavity is filled with heterogeneous dense or short strip echo. "Snow-like", when the blisters are large, the echogenic area is "honeycomb", the uterine wall is thin, but the echo is continuous, there is no focal translucent area, and sometimes the ovarian flavin is measured on both sides or one side. Cysts, multiple rooms, thin wall, partial fine separation inside, color Doppler ultrasonography see uterine artery blood flow, but no blood flow in the myometrium or only sparse "star-like" blood flow signal.
3 Ultrasound Doppler examination: the fetal heart can not hear the fetal heart, only the uterine blood flow murmur can be heard, and the normal pregnancy can hear the fetal heart at the earliest 6 to 7 weeks of pregnancy.
3. Dysfunctional uterine bleeding: can also occur in women of childbearing age.
(1) Menopause time: due to the disorder of the menstrual cycle, sometimes mistaken for menopause.
(2) vaginal bleeding: common symptoms are irregular vaginal bleeding, characterized by menstrual cycle disorders, menstrual cycle length, bleeding volume for a long time, or even a lot of bleeding, lasting 2 to 3 weeks or more, not easy to stop.
(3) Abdominal pain: There is no abdominal pain during dysfunctional uterine bleeding, and there is often lower abdominal pain during abortion.
(4) Gynecological examination: There are no organic lesions in the internal and external reproductive organs.
(5) Auxiliary examination: negative pregnancy test; diagnostic curettage, sent pathological examination, no pregnancy or pregnancy endometrial changes, can rule out miscarriage.
4. Uterine fibroids
(1) Menopause time: The patient has no obvious history of menopause.
(2) vaginal bleeding: uterine fibroids typically have menorrhagia, menstrual cycle shortened, menstrual period prolongation and infertility; submucosal fibroids with necrosis, there may be persistent irregular vaginal bleeding or bloody purulent drainage.
(3) Abdominal pain: usually no abdominal pain, acute abdominal pain occurs when the subserosal fibroids are reversed, abdominal pain is severe with fever when the fibroids are red, and sub-abdominal pain can be caused by submucosal fibroids secondary infection. Common symptoms include lower abdominal bulge. Back pain, increased menstruation.
(4) gynecological examination: intermuscular fibroids uterus increased, the texture is hard, the surface has irregular fibroid nodules; subserosal fibroids can touch the hard, globular mass and the uterus have fine pedicles, good activity Submucosal fibroids uterus uniform enlargement, sometimes cervical dilatation, fibroids located in the cervical canal or prolapse to the vagina, red, parenchy, smooth surface of the ball, accompanied by exudate or superficial ulceration on the surface of the infection, and There is purulent drainage. If the fibroids are cystic, the texture becomes soft and it is easy to be misdiagnosed as a pregnant uterus.
(5) Auxiliary examination: negative pregnancy test; B-mode ultrasound examination showed a round hypoechoic fibroid, and can determine whether the fibroids have degeneration.
5. Pregnancy with cervical erosion or polyp bleeding: This type of bleeding is not accompanied by lower abdominal pain, blood volume is small but the color is bright red, speculum examination sees cervical erosion or active bleeding at the polyps, the size of the uterus is consistent with the pregnancy month, B-mode ultrasound Check for signs of abnormality.
6. Choriocarcinoma: The common point with threatened abortion is that both are women of childbearing age, all have vaginal bleeding and uterine enlargement, choriocarcinoma vaginal bleeding occurs in hydatidiform mole, abortion or full-term postpartum, prone to lung, Vaginal, brain and other parts of the metastasis, uterus enlargement, soft, irregular shape, endometrial histological examination of a large number of nourishing cells and bleeding, necrosis, no villus structure can be diagnosed, B-mode ultrasound showed no intrauterine Pregnancy signs, suspected of metastasis, further X-ray film, CT examination and other assistance to diagnose.
7. Pregnancy corpus callosum rupture: sudden menstrual pain on the lower abdomen after menopause, no vaginal bleeding, no shock or mild shock, gynecological examination of cervical pain, tenderness on one side of the attachment area, dark red after the puncture of the dome Coagulation, B-mode ultrasound revealed a low echo area in the attachment area on one side.
8. Membrane-like menstruation: menstrual period of abdominal pain or menstrual period for several days, with menstrual blood excretion of membrane-like tissue, easily misdiagnosed as miscarriage, negative pregnancy test, discharge tissue sent pathological examination for the endometrium, no villus can be diagnosed.
9. Pregnancy with cervical cancer: manifested as irregular vaginal bleeding, or often bloody secretions, especially vaginal examination or bleeding after sexual intercourse, gynecological examination and cervical biopsy for cancer, can be diagnosed.
10. Cervical pregnancy
There is a history of menopause and a history of early pregnancy, beginning with a small amount of irregular vaginal bleeding or only a history of bloody secretions, followed by a gradual increase in blood flow, which may be intermittent vaginal bleeding, but also a sudden large amount of bleeding leading to shock, a large number of bleeding often occurs In the 3 months of pregnancy, the amount of bleeding is more than that of intrauterine pregnancy. When the hematoma is formed at the bottom of the broad ligament, abdominal pain occurs. Gynecological examination: the cervix is significantly enlarged, the soft color is stained, and the change of the size and hardness of the uterus is not obvious. Development, the cervix is conical, the outer edge of the cervix is thin, congested, the outer mouth is invaginated, the internal cervix is closed, the vaginal bleeding comes from the cervical canal and flows out through the small hole, B-mode ultrasound: normal uterus Large or slightly larger, there is no gestational sac in the uterine cavity, the cervical canal is enlarged and thickened, and the gestational sac can be diagnosed in the cervical canal. The diagnostic criteria for cervical pregnancy:
1 The site of the placenta attachment must have a cervical gland;
2 placenta and the wall of the cervix should be closely attached;
3 all or most of the placenta tissue below the internal cervix;
4 no intrauterine pregnancy.
11. Red degeneration of uterine fibroids: more common in pregnancy, a history of uterine fibroids, manifested as severe pain in the lower abdomen with high fever, check the rapid increase of fibroids, gynecological examination of the uterus has tenderness, and can touch the painful mass, B-mode ultrasonography showed echoes of degenerative fibroids in the uterine muscle wall.
