recurrent miscarriage
Introduction
Introduction to recurrent abortion A spontaneous abortion that occurs 2 or more times in a row is called recurrent spontaneous abortion (RSA). Abortion refers to those who terminate before 28 weeks of gestation and whose fetal weight is below 1000 grams. In 1977, the World Health Organization (WHO) defined abortion as being terminated before 20 weeks of gestation and weighing less than 500 grams. The classical theory defines a spontaneous abortion that occurs three or more times in a row as a habitual abortion. basic knowledge Probability ratio: 0.55% of women with gestational age Susceptible population: pregnant women Mode of infection: non-infectious Complications: septic shock female infertility pelvic inflammatory infertility
Cause
Cause of recurrent spontaneous abortion
Only 50% of patients with recurrent spontaneous abortion can identify their causes, including chromosomal abnormalities, maternal genital tract abnormalities, maternal secretion abnormalities, immune dysfunction, reproductive tract infections, cervical insufficiency, and thrombotic tendency.
Chromosomal abnormality
Including couple chromosomal abnormalities and embryo chromosomal abnormalities. Common couple chromosomal abnormalities are balanced translocation, Robertson translocation and so on.
2. Maternal endocrine disorders
(1) luteal insufficiency accounts for 23% to 60%, basal body temperature is biphasic, but high temperature phase is less than 11 days, or high and low temperature difference is less than 0.3, endometrial biopsy shows secretion reaction at least 2 days behind, luteal phase progesterone is lower than 15ng/ml caused a poor decidual reaction in pregnancy, and 2 to 3 cycles of luteal function test showed insufficient, in order to be included in the diagnosis, luteal insufficiency affects the implantation of pregnant eggs.
(2) In patients with recurrent spontaneous abortion of polycystic ovary syndrome, the incidence of polycystic ovary syndrome was 58%. High concentrations of luteinizing hormone, high androgen and hyperinsulinemia reduce egg quality and endometrial receptivity.
(3) Hyperprolactinemia The presence of prolactin receptors in luteal cells, high prolactin inhibits granulocyte luteinization and steroid hormones, leading to luteal insufficiency and decreased egg quality. Some scholars have found that prolactin can reduce the secretion of chorionic gonadotropin in early human placenta.
(4) Thyroid disease Thyroid dysfunction is associated with recurrent spontaneous abortion. Moreover, recurrent spontaneous abortion is thought to be associated with the presence of thyroid antibodies (the thyroid function is mostly normal in such patients).
(5) Diabetic subclinical or controlled diabetes does not lead to recurrent spontaneous abortion, and the spontaneous abortion rate of uncontrolled insulin-dependent diabetes is increased.
3. Abnormalities of the maternal reproductive tract
(1) uterine malformation 15% to 20% recurrent spontaneous abortion is associated with uterine malformation. Including single-horned uterus, double-horned uterus, double uterus and uterine mediastinum. Among them, especially the uterine incomplete mediastinum is the most likely to cause recurrent miscarriage. Intima is poorly developed in the mediastinum, is not sensitive to steroid hormones, and has a poor blood supply.
(2) Asherman syndrome has a reduced uterine cavity volume and a decreased response to steroid hormones.
(3) Cervical insufficiency causes late abortion and premature birth, accounting for 8% of recurrent spontaneous abortion. Cervical insufficiency refers to the disappearance of the cervical canal that is painless during pregnancy and the expansion of the cervix. The non-pregnancy No. 8 Hagar expansion rod has no resistance through the internal cervix.
(4) submucosal fibroids of uterine fibroids and myometrial fibroids larger than 5 cm are associated with recurrent spontaneous abortion.
4. Genital tract infections
0.5% to 5% of recurrent abortions are associated with infection. The incidence of abortion and preterm birth in patients with bacterial vaginosis is increased in late pregnancy; endometritis or endocarditis caused by Chlamydia trachomatis and Ureaplasma urealyticum can cause miscarriage.
5. Immune function abnormalities
(1) Autoimmune antiphospholipid antibody syndrome (APS): a group of clinical signs of antiphospholipid antibody positive with thrombosis or pathological pregnancy. It is caused by thromboembolism caused by anti-phospholipid antibodies activating various pathways such as vascular endothelium and platelets, and can also damage trophoblast cells. APS is characterized by having at least one clinical and laboratory standard. The clinical criteria are: 11 or more confirmed thrombosis, including thrombosis of veins, arteries and small blood vessels; 2 pregnancy complications including 3 or more less than 10 weeks of pregnancy loss; 31 or more times greater than 10 pregnancy Weekly fetal death or at least one premature birth due to pre-eclampsia or placental dysfunction. Laboratory standards: anti-cardiolipin antibodies (IgG or IgM) moderately above or lupus anticoagulant and 2 glycoprotein 1 antibody positive. The above three test intervals were repeated at least twice in 6 weeks.
(2) Allogeneic pregnancy is a successful semi-allogous transplantation process. Pregnant women develop a series of adaptive changes due to the autoimmune system, thereby showing immune tolerance to intrauterine embryo transfer without rejection. If immune regulation and inhibition of cell imbalance, such as trophoblastic membrane HLA-G expression abnormality, NK cell subset imbalance, Th1/Th2 balance imbalance, protective antibodies and / or blocking antibodies abnormal, macrophage secretion of cytokines abnormal, The mother's abnormal recognition of the embryo's paternal antigen produces immunoreactivity, resulting in maternal blocking antibody or protective antibody deficiency, immune rejection, and miscarriage.
6. Hereditary thrombosis
Hereditary thrombotic tendency: such as factorVLeiden gene mutation and methylenetetrahydrofolate reductase (MTHFR) gene expression abnormality, protein S, protein C deficiency lead to thrombosis tendency affects placental development and function.
7. Other
Unhealthy lifestyles are associated with abortion. Some scholars have reported that women who smoked more than 14 cigarettes a day had a two-fold increased risk of miscarriage compared with the control group. Alcohol abuse, excessive caffeine consumption, and environmental factors such as organic solvents and poisons. Obesity is associated with early abortion and recurrent miscarriage.
Prevention
Recurrent abortion prevention
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
Recurrent abortion complications Complications , septic shock, female infertility, pelvic inflammatory infertility
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 recurrent miscarriage Common symptoms Lower abdominal pain Vaginal discharge Fragment tissue Irregular vaginal bleeding
Two or more spontaneous abortions occur continuously. During abortion, vaginal bleeding and abdominal pain can occur after menopause. Some patients have no clinical symptoms.
Examine
Recurrent abortion check
In the diagnosis of recurrent abortion, the relevant medical history should be inquired in detail, physical examination should be completed, and related auxiliary examinations should be carried out to find the cause.
History
(1) History of abortion: the month, characteristics and form of abortion;
(2) menstrual history;
(3) history of infection;
(4) a history associated with endocrine abnormalities such as thyroid function, prolactin, glucose metabolism, and hyperandrogenism;
(5) History of individuals and family thrombosis;
(6) characteristics associated with antiphospholipid antibody syndrome;
(7) History of other autoimmune diseases;
(8) Lifestyle: mainly smoking, alcohol abuse, excessive caffeine and medication history during pregnancy;
(9) family history, history of obstetric complications, history of syndromes associated with fetal loss;
(10) Past history of diagnosis and treatment.
2. Physical examination
(1) General general condition examination: presence or absence of obesity, hairy, thyroid examination, presence or absence of galactorrhea.
(2) pelvic examination, especially with or without genital malformations and infections.
3. Auxiliary inspection
(1) Fallopian tube angiography, hysteroscopy, ultrasound examination;
(2) Chromosomal screening of both couples;
(3) Six female blood sex hormones, thyroid hormone and its autoantibodies, blood sugar and insulin resistance tests;
(4) detection of anticardiolipin antibodies or lupus anticoagulant factors, anti-2 glycoprotein-1 antibodies;
(5) homocysteine;
(6) factorVLeidenmutation, protein S, protein C examination;
(7) blood routine and its clotting factor check;
(8) Examination of platelet aggregation degree;
(9) Blood type examination of both parties;
(10) ovarian reserve function test;
(11) Men's semen examination.
Diagnosis
Diagnosis of recurrent spontaneous abortion
In the diagnosis of recurrent abortion, the relevant medical history should be inquired in detail, physical examination should be completed, and related auxiliary examinations should be carried out to find the cause and diagnose.
Differential diagnosis: First, distinguish the type of abortion. At the same time, it needs to be differentiated from ectopic pregnancy, hydatidiform mole, dysfunctional uterine bleeding, pelvic inflammatory disease and acute appendicitis.
