What Is a Therapeutic Abortion?

A spontaneous abortion that occurs 2 or more times in a row is called recurrent abortion (RSA). Abortion refers to those who terminate before 28 weeks of pregnancy and whose fetal weight is less than 1000 grams. In 1977, the World Health Organization (WHO) defined miscarriages as those who terminated before 20 weeks of pregnancy and had a fetal weight of less than 500 grams. Classical theory defines spontaneous abortion as three or more consecutive spontaneous abortions as habitual abortion.

Basic Information

English name

recurrent abortion

Visiting department

Obstetrics and Gynecology

Common causes

Chromosomal abnormalities, Maternal reproductive tract abnormalities, Maternal endocrine abnormalities, Immune abnormalities, Reproductive tract infections, Cervical insufficiency, Tendency to thrombosis, etc.

Common symptoms

Vaginal bleeding and abdominal pain after menopause

Causes of recurrent miscarriage

Only 50% of patients with recurrent miscarriage can identify the cause, which mainly includes chromosomal abnormalities, maternal reproductive tract abnormalities, maternal endocrine abnormalities, immune dysfunction, reproductive tract infections, cervical insufficiency, and thrombosis 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 dysfunction accounts for 23% to 60%, basal body temperature is biphasic, but the high temperature phase is less than 11 days, or the difference between high and low temperature is less than 0.3. Endometrial biopsy shows that the secretory response is at least 2 days behind, and the progesterone in the luteal phase is 15 ng / ml caused a poor decidual response in pregnancy, and luteal function tests showed insufficient in 2 to 3 cycles before they could be included in the diagnosis. Luteal dysfunction affects pregnancy egg implantation.

(2) In patients with recurrent spontaneous abortion of polycystic ovary syndrome, the incidence of polycystic ovary syndrome is 58%. High concentrations of luteinizing hormone, hyperandrogens and hyperinsulinemia reduce egg quality and endometrial receptivity.

(3) Prolactin receptors are present in luteal cells of hyperprolactinemia . Hyperprolactin inhibits luteinization and steroid hormones of granulocytes, leading to luteal insufficiency and decreased egg quality. Some scholars have found that prolactin can reduce the secretion of human placental chorionic gonadotropin in early stage.

(4) Thyroid disease Hypothyroidism is associated with recurrent spontaneous abortion. It is also believed that recurrent spontaneous abortion is related to the presence of thyroid antibodies (most of these patients have normal thyroid function).

(5) Diabetic subclinical or well-controlled diabetes will not lead to recurrent miscarriage, and spontaneous abortion of uncontrolled insulin-dependent diabetes mellitus will increase.

3. Maternal reproductive tract abnormalities

(1) 15% to 20% of recurrent spontaneous abortions are associated with uterine malformations. Including single horn uterus, double horn uterus, double uterus and mediastinum. Among them, uterine insufficiency and mediastinum are most likely to cause recurrent miscarriage. The endometrium of the mediastinum is poorly developed, is not sensitive to steroid hormones, and has poor blood supply.

(2) Asherman syndrome reduces the uterine cavity volume and decreases the response to steroid hormones.

(3) Cervical insufficiency causes late abortion and premature delivery, accounting for 8% of recurrent abortions. Cervical insufficiency means: painless cervical canal disappears during pregnancy, and the cervix is dilated. The non-pregnant No. 8 Hagar expansion rod passes through the internal cervix without resistance.

(4) Uterine fibroid submucosal fibroids and intermuscular fibroids larger than 5 cm are associated with recurrent miscarriage.

4. Reproductive tract infection

Recurrent miscarriage of 0.5% to 5% is associated with infection. Patients with bacterial vaginosis have an increased incidence of miscarriage and premature delivery in late pregnancy; endometritis or cervical inflammation caused by chlamydia trachomatis and mycoplasma urealyticum can cause abortion.

5. Immune dysfunction

(1) Autoimmune antiphospholipid antibody syndrome (APS): A group of clinical signs of antiphospholipid antibody positive with thrombosis or pathological pregnancy. The reason is that anti-phospholipid antibodies activate vascular endothelium and platelets to cause thromboembolism, which can also damage trophoblast cells. APS is characterized by having at least one clinical and laboratory standard. The clinical criteria are: thrombosis diagnosed one or more times, including thrombosis of veins, arteries, and small blood vessels; pregnancy complications include three or more pregnancy losses of less than 10 weeks; one or more than 10 pregnancy Fetal death or at least one premature birth due to preeclampsia or placental insufficiency. Laboratory standards: Moderate levels of anticardiolipin antibody (IgG or IgM) or positive for lupus anticoagulant factor and 2 glycoprotein 1 antibody. The above three tests should be repeated at least twice every 6 weeks.

(2) Immune pregnancy is a successful semi-isogeneic transplantation process. The pregnant woman has a series of adaptive changes due to the autoimmune system, thereby showing immune tolerance to the intrauterine embryo graft without rejection. If immune regulation and suppression of cell imbalances, such as abnormal expression of trophoblast membrane HLA-G, imbalance of NK cell subsets, imbalance of Thl / Th2, abnormalities of protective antibodies and / or blocking antibodies, abnormalities of cytokines secreted by macrophages The mother's abnormal recognition of the embryo's paternal antigen results in a low immune response, which results in the lack of maternal blocking antibodies or protective antibodies, immune rejection, and miscarriage.

6. Hereditary thrombotic tendency

Hereditary thrombotic tendencies: such as the mutation of the factorVLeiden gene and abnormal expression of the methylenetetrahydrofolate reductase (MTHFR) gene. The lack of protein S and protein C leads to the tendency of thrombosis to affect the development and function of the placenta.

7. Other

An unhealthy lifestyle is associated with miscarriage. Some scholars have reported that women who smoke more than 14 cigarettes a day have twice the risk of miscarriage compared to the control group. The effects of alcohol, excessive caffeine consumption, and environmental factors such as organic solvents and poisons. Obesity is associated with early and recurrent miscarriages.

Clinical manifestations of recurrent miscarriage

Two or more spontaneous spontaneous abortions occurred in succession. Vaginal bleeding and abdominal pain after menopause can be manifested during abortion, and some patients have no clinical symptoms.

Diagnosis of recurrent miscarriage

When recurrent abortion is diagnosed, the related medical history should be asked in detail, physical examination should be improved, and related auxiliary examinations should be performed in an effort to find the cause.

Medical history

(1) History of abortion: month, characteristics and forms of abortion;

(2) History of menstruation;

(3) History of infection;

(4) History related to endocrine abnormalities such as thyroid function, prolactin, glucose metabolism, androgenemia;

(5) Personal and family history of thrombosis;

(6) Features related to anti-phospholipid antibody syndrome;

(7) History of other autoimmune diseases;

(8) Lifestyle: Mainly smoking, alcoholism, excessive caffeine and medication history during pregnancy;

(9) Family history, history of obstetric complications, and history of syndromes related to fetal loss;

(10) Past diagnosis and treatment history.

2. Physical examination

(1) Routine general general examination: whether there is obesity, hairy, thyroid examination, whether there is galactorrhea, etc.

(2) Pelvic examination, especially for reproductive tract malformations and infections.

3. Auxiliary inspection

(1) Fallopian tube angiography, hysteroscopy, ultrasound examination;

(2) chromosome screening of both spouses;

(3) The woman's six blood sex hormones, thyroid hormones and their autoantibodies, blood glucose and insulin resistance tests;

(4) Detection of anticardiolipin antibody or lupus anticoagulant factor and anti2 glycoprotein-1 antibody;

(5) homocysteine;

(6) factorVLeidenmutation, protein S, protein C inspection;

(7) blood routine and coagulation factor examination;

(8) Examination of platelet aggregation;

(9) Examination of blood type of both parties;

(10) Examination of ovarian reserve function;

(11) Men's semen examination.

Differential diagnosis of recurrent miscarriage

First distinguish the type of miscarriage. It also needs to be distinguished from ectopic pregnancy, hydatidiform mole, dysfunctional uterine bleeding, pelvic inflammatory disease, and acute appendicitis.

Recurrent Abortion Treatment

Patients with recurrent miscarriage, choose different treatment methods for different causes:

1. Treatment of corpus luteum insufficiency

Application of clomiphene and HMG to promote follicular development; after basal body temperature rises, human chorionic gonadotropin 1000-2000U, intramuscular injection every other day to stimulate luteal function; progesterone replacement luteal function therapy.

2. Treatment of polycystic ovary syndrome

Weight control, oral metformin, luteal support during pregnancy.

3. Treatment of hyperprolactinemia

Bromocriptine, the initial dose of 1.25mg, taken every night before bedtime, the amount can be gradually increased to 2.5mg, once or twice a day, if the dose is not reached can be further increased. Drug therapy maintains effective low doses. Application during pregnancy is controversial.

4. Maintain normal thyroid function

Thyroid tablets are used in patients with low thyroid function, and thyroid hormones during pregnancy are normal for those with normal thyroid hormones but positive for thyroid antibodies.

5. Correct uterine anatomy abnormalities

Hysterectomy, hysterectomy, submucosal fibroid removal. Whether single-shot uterine fibroids larger than 5 cm need to be removed is controversial. Cervical insufficiency can be selected for cervical insufficiency.

6. Treatment of antiphospholipid antibody syndrome

Reports in the literature indicate that oral aspirin and / or prednisone combined with low-dose prednisone have certain effects, and combined with low-dose heparin has also been reported.

7.Treatment of patients with hereditary thrombotic tendencies

Patients with hypercysteineemia caused by abnormal expression of methylenetetrahydrofolate reductase (MTHFR) gene are supplemented with folic acid, vitamins B ₆ and B ₁₂ . Such as factorVLeiden gene mutation, protein S or protein C deficiency may consider the application of heparin anticoagulation during pregnancy.

8.Treatment of patients with unexplained recurrent abortion

Patients who have eliminated the above-mentioned causes and who meet the diagnosis of recurrent miscarriage become unexplained recurrent miscarriage. Its treatment methods mainly include active immunity and passive immunotherapy.

References:

1. Wang Yan, Chen Guian, etc. Correlative study on the expression of interleukin 2 and interleukin 4 at the maternal-fetal interface of recurrent abortion with unknown causes: Journal of Reproductive Medicine, 2005: 14 (4) 208-213.

2. Lin Qide. Basic and clinical research progress of recurrent abortion that should have been unknown: Chinese Journal of Obstetrics and Gynecology, 2003: 38 (8): 481-3.