Remains of the fertilized egg after medical termination of pregnancy. What to do if the pregnancy continues after an abortion

Today, many women, for certain reasons, decide to terminate their pregnancy and choose medical abortion, believing that it is the safest. However, this entails many complications, one of which is considered incomplete abortion. In addition, a similar condition can also occur as a result of a miscarriage.

Incomplete spontaneous abortion

Spontaneous ends in miscarriage or premature birth non-viable fetus. The question of how long the fetus can remain viable is quite controversial. Today, abortion is considered to be the termination of pregnancy before the 20th week or the birth of a fetus weighing less than 500 grams.

Incomplete spontaneous abortion means that placental abruption occurs, resulting in severe bleeding with particles of the fertilized egg. The situation is complicated by the fact that all signs of pregnancy disappear, but at this time serious violations occur. In some cases, a woman may experience attacks of nausea and pain in the pelvic area.

Incomplete medical abortion

Sometimes particles of the fertilized egg can remain in the uterine cavity even after a medical abortion. Incomplete medical abortion occurs after taking certain medications. There are many reasons why such a violation can occur. Knowing exactly what causes such a condition exist, you need to take the process of abortion very responsibly and take appropriate measures to ensure that the abortion is as safe as possible.

Incomplete vacuum interruption

Incomplete abortion with vacuum is quite rare. This is a very serious consequence, characterized by the fact that the fertilized egg remains partially or completely in the uterine cavity. In addition, membranes may remain in the uterine cavity. Such a violation can occur as a result of an incorrectly performed procedure, a violation of the structure of the uterus, or previous infectious diseases.

To prevent the risk of incomplete abortion, care must be taken to comprehensive examination. This will allow you to determine the location of the fertilized egg before the procedure.

Causes of incomplete abortion

Dangerous complications after abortion can lead to the development of sepsis. There are certain reasons for incomplete abortion, among which the following should be highlighted:

• medical error;
• hormonal disorders;
• performing an abortion on later;
• heredity;
• food poisoning;
• inflammatory processes.

All these factors can lead to the fact that the expulsion of the fetus from the uterine cavity may be incomplete. As a result, infection may occur and additional curettage may be required. All these complications can lead to infertility.

Main symptoms

The first signs of incomplete abortion are observed literally 1-2 weeks after the operation. The main symptoms are considered:

• nagging and sharp pain in the pelvic area;
• temperature increase;
• pain on palpation of the abdomen;
• heavy bleeding;
• symptoms of intoxication.

When the first signs appear, you should definitely consult a doctor for diagnosis and subsequent treatment. Such a violation can have a detrimental effect on a woman’s health, as well as her reproductive system. In particularly severe cases, this can lead to death.

Diagnostics

A comprehensive diagnosis is required, which includes:

• blood tests;
• pressure measurement;
• ultrasound diagnostics.

In addition, inspection of the cervix and palpation are required. Only comprehensive diagnostics will help determine the presence of fetal remains.

Carrying out treatment

If an incomplete abortion occurs, emergency care should be provided immediately after the first signs of a disorder occur. In case of severe bleeding, a large-diameter venous catheter is installed and an Oxytocin solution is injected. In addition, it is imperative to remove any remaining fruit. If curettage occurred without complications, then observation is indicated for several days, and then the patient is discharged.

If there is significant blood loss, administration of ferrous sulfate is indicated. To eliminate pain, Ibuprofen is prescribed. When the temperature rises, the use of antipyretic drugs is indicated.

Psychological support

After a spontaneous abortion, a woman often feels guilty and stressed. It is important to provide her with competent psychological assistance. It is advisable for a woman to contact a psychological support group. It is important not to rush into your next pregnancy, as some time must pass for the body to recover.

Possible complications

The consequences and complications can be very serious, ranging from prolonged bleeding to inflammatory processes and even sepsis. Complications are divided into early and late. Early ones are observed immediately after an abortion or miscarriage, and include:

• discharge;
• penetration of infection;
• chronic inflammation of the uterine cavity.

Late complications can occur several months or even years after the abortion. These may be adhesive processes, hormonal disorders, as well as deterioration in the functioning of the reproductive sphere.

Prevention of complications

Compliance with certain simple rules will help significantly reduce the risk of complications. It is imperative to avoid sexual relations in the first 3 weeks after an abortion or miscarriage. Control of secretions is required, it is important to avoid physical activity for 2 weeks, follow basic hygiene rules. During the first month it is forbidden to swim in the bathroom, the sea, or use tampons. In addition, it is important to regularly visit a gynecologist for examination. After a medical abortion or spontaneous miscarriage, you need to visit a doctor a week later and make sure that all the remains of the fetus are expelled.

In order to remove the remnants of the fertilized egg from the uterus, it is used digital and instrumental emptying of the uterus. In this case, it is not necessary for the cervix to be wide open; if the opening is insufficient, the cervical canal can be expanded using metal dilators. Usually, with an incomplete miscarriage, there is no need to resort to pain relief, since the most painful part of the operation - dilation of the cervix - is eliminated.

The instrumental method, compared to the finger method, is less dangerous in terms of introducing infection into the uterus from the vagina, and requires less time and stress during manipulation. The main disadvantage of the instrumental method is the risk of damage to the uterine wall, which may be accompanied by bleeding or perforation of the uterus. In addition, during instrumental evacuation of the uterus, it is more difficult to decide whether all pieces of the fertilized egg have been removed. Careful performance of the operation and the well-known practical experience of the doctor help to avoid these complications during instrumental evacuation of the uterus, and this method is generally accepted.

Finger method for removing parts of the fertilized egg Along with its advantages, it also has a number of significant disadvantages; it is used relatively rarely and mainly during pregnancy over 12 weeks. Removing the fertilized egg with a finger is possible only when the cervix is ​​dilated, allowing the finger to enter the uterine cavity (Fig. 8).

Rice. 8. Digital emptying of the uterus during miscarriage.

Digital evacuation of the uterus is more painful than instrumental evacuation because after insertion into the uterus index finger With one hand, the other grasps the uterus through the abdominal wall and, pressing downwards, as if placing it on a finger located in the uterus. This causes pain, the woman begins to tense abdominal wall, interferes with the manipulations performed. The operator tries to overcome the reflex contraction of the abdominal muscles, which further increases the pain. In some cases, in order to complete the operation and stop the bleeding, the doctor is forced to resort to anesthesia or proceed to instrumental evacuation of the uterus.

The finger method is also more dangerous in terms of introducing infection, because no matter how you prepare your hand, it, passing through the vagina, will carry flora from it into the cervix or even into the uterine cavity. Meanwhile, during instrumental emptying of the uterus, the instrument, without touching the walls of the vagina, is inserted directly into the cervix.

However, the finger method has significant advantages, namely: the operator’s finger feels well the wall of the uterus and the parts of the fertilized egg attached to it; detachment and removal of pieces of membranes from the uterus are carried out carefully; the finger does not cause damage to the walls of the uterus; By examining the uterine cavity and its walls with a finger, the doctor can clearly check whether pieces of the fertilized egg have been completely removed. When performing digital removal of the fertilized egg during late miscarriages, it should be taken into account that on one of the walls of the uterus a rough surface is detected in the area where the child’s place is attached.

The doctor, using this method, first carefully peels off pieces of the fertilized egg with his finger from the underlying uterine wall and gradually pushes them out of the uterine cavity into the vagina. Then he carefully checks the walls of the uterus with his finger and removes the remaining pieces of the fertilized egg from the cavity. Loose fragments of the falling shell come out unnoticed during manipulation.

The finger method cannot be completely rejected, but it is used in rare cases, namely: for late miscarriages with severe bleeding and especially for infected miscarriages that require emergency care. In case of late miscarriages, the digital method can be used as the first stage of the operation, and after the uterus has emptied, when it contracts, curettage is performed to remove the remnants of the fertilized egg.

In most cases it is most appropriate to use instrumental method for removing the remains of the fetal egg (curettage or vacuum aspiration). Curettage of the uterine cavity or instrumental examination must be performed under local or short-term general anesthesia. Using probing of the uterus (Fig. 9), the length of the uterine cavity and cervical canal is measured. If the cervical canal is sufficiently dilated after probing, the curettage operation begins. If the cervical canal is not sufficiently opened, then it is expanded with metal Hegar dilators, introducing them sequentially, number by number (Fig. 10). During pregnancy up to 2-2.5 months, the cervical canal is expanded with bougies to No. 12, and during pregnancy of about 3 months - to No. 14.

Rice. 9. Probing of the uterus.

Rice. 10. Dilatation of the cervix with metal bougies.

The patient is placed on the operating table in the dorso-gluteal position. The sister shaves the hair on the external genitalia and pubic area, washes this area and the inner thighs with a 2% chloramine solution and wipes it dry with a piece of sterile cotton wool. The external genitalia are wiped with alcohol and lubricated with 5% tincture of iodine; in this case, the anus is covered with a cotton swab. Sterile long cloth stockings are put on the patient’s legs; The external genitalia are covered with a sterile napkin with a rectangular incision. A grooved speculum is inserted into the vagina, held by an assistant standing to the right of the patient. Cotton balls grasped with long tweezers remove blood clots and liquid blood accumulated in the vagina. The vaginal part of the cervix is ​​wiped with alcohol and lubricated with 5% tincture of iodine. Visible in the depths vaginal part cervix with a wide open pharynx and parts of the membranes of the fertilized egg protruding from it. Grab the anterior lip of the pharynx with two bullet forceps, and, holding them with your left hand, pull the cervix to the entrance to the vagina. After this, they take an abortion forceps and grab parts of the fetal egg lying in the cervical canal (Fig. 11). By slowly rotating the abortion forceps, parts of the membranes soaked in blood are removed from the cervix. After this, the operator takes a large blunt curette (Fig. 12) and, grasping it with three fingers, like a writing pen, carefully inserts it without any violence into the uterine cavity and reaches its bottom, which is felt as some resistance to the advancement of the curette (Fig. 13).

Having noticed the depth to which the curette has entered, the operator begins curettage, moving the curette from top to bottom and pressing it against the anterior wall of the uterus. In this case, the remnants of the membranes are separated from the wall of the uterus, which fall out of the wide open external pharynx. The operator again carefully inserts the curette to the fundus of the uterus and then vigorously moves the curette from the fundus to the internal os, pressing it against the wall of the uterus. Such movements with a curette are carried out sequentially along the anterior, right, posterior and left walls of the uterus, separating the parts of the membranes attached to them, which fall into the vagina. As curettage progresses, the bleeding intensifies, which is explained by the separation of the membranes from the walls of the uterus. This shouldn't be confusing. As soon as all remnants of the fertilized egg are removed from the uterus, it will contract and the bleeding will stop.

Rice. 11. Parts of the fertilized egg lying in the cervical canal are captured and removed using an abortion forceps.

Rice. 12. Curettes.

Rice. 13. Position of the curette in the hand when curettage of the uterus: a - insertion of the curette into the uterine cavity; b - removal of the curette from the uterine cavity.

For curettage, the operator takes a smaller curette, carefully inserts it into the uterine cavity and to the fundus and notices that the latter has decreased as the uterus has contracted. Using a small curette, all the walls of the uterus and, mainly, the corners of the cavity are sequentially checked. When scraping, a characteristic crunch is heard (the sound that occurs when the curette moves along the muscles of the uterus), scraping is no longer possible, and a small amount of foamy blood fluid is released from the uterus. The scraping is completed. The bleeding has stopped. Remove the bullet forceps and remove the mirror. The operation is completed.

Upon completion of curettage, the uterus should be placed in a position tilted anteriorly (Fig. 14).

Rice. 14. Bringing the uterus after curettage to the antiversion position.

An abortion tang, which has a rounded jaw, is used to remove parts of the fertilized egg lying in the cervical canal, speeds up the emptying of the uterus. However, its use, and especially forceps, can lead to damage to the uterus and abdominal organs. The perforation made by these forceps-like instruments is usually large, and the doctor, not noticing the perforation, opens the instrument to grab the fertilized egg, further tearing the uterine wall. An intestinal loop can be captured in an open abortion forceps or forceps, which is torn from the mesentery when removed. The intestine may be crushed or ruptured, causing its contents to leak into the abdominal cavity, which can lead to bleeding and peritonitis.

Therefore, it is better to remove only the parts of the fertilized egg that are visible to the eye and lying in the cervix (see Fig. 11). Only a qualified obstetrician can afford to insert the abortion tool beyond the internal os.

Forceps should not be used. The most severe damage occurs when using this tool.,

In the USSR (1966), a method was developed and equipment was created for terminating pregnancy using vacuum aspiration (E.I. Melke, 1961, 1966; A.V. Zubeev, 1962).

Subsequently, many models of vacuum devices for abortion appeared, both domestic (V. S. Lesyuk, 1962; D. Andreev, 1963) and foreign authors.

Emergency care in obstetrics and gynecology, L.S. Persianinov, N.N. Rasstrigin, 1983

Intrauterine contraceptives

Lipps loop (prohibited for use) during longitudinal scanning is determined in the form of rounded hyperechoic inclusions in the uterine cavity, distal to which an acoustic shadow is clearly visualized. A transverse scan of the Lipps loop shows several linear hyperechoic inclusions at several levels from the fundus to the internal os. T-shaped contraceptives are scanned longitudinally as a linear hyperechoic structure with echo shadow, and transversely as a small round hyperechoic formation, also with a pronounced acoustic shadow. (Fig. 1-5)

criterion correct location intrauterine contraceptive device (IUC) is the visualization of its distal end in the projection of the bottom of the uterine cavity (Fig. 1). When determining the distal part of the ICH in the upper third cervical canal, and the proximal part in the lower part of the uterine cavity, we can conclude that the IUD is partially expulsed into the cervical canal (Fig. 6), or the IUD is located low. Full expulsion of the IUD into the cervical canal is characterized by an echo pattern in which the entire IUD is located in the cervical canal (Fig. 7). A very difficult diagnostic task is to search for a normally or low-lying IUD during pregnancy (Fig. 8). This often fails, especially over long periods. Another option for incorrect placement of the IUD in the uterine cavity is its oblique location. The criterion for this pathological condition is the inability to trace the IUD along its entire length with a strictly sagittal scan of the uterine cavity (Fig. 9). Ultrasound examination also makes it possible to visualize ICH complications such as myometrial perforation (Fig. 9-b) and fragmentation of the contraceptive.

Remains of fertilized egg

The echographic picture of the remains of the ovum after termination of pregnancy is very diverse. This is due to the gestational age at which the abortion was performed, as well as the morphological substrate of the remains - chorionic and decidual tissue, embryo fragments, blood clots, liquid blood, etc. (Fig. 10-13). Differential ultrasound diagnosis of these structures can be very difficult due to the similarity of echographic signs (heterogeneous heterogeneous contents). As A.M. rightly points out. Stygar, in these cases, dynamic observation data are decisive: blood clots are gradually destroyed, while chorionic tissue is difficult to destroy. The author recommends watchful waiting in the presence of formations less than 1 cm in diameter - during next menstruation they can "come out". When visualizing hematometers (Fig. 10), the tactics depend on the degree of expansion of the uterine cavity. A slight expansion (up to 1-2 cm) with homogeneous echo-negative content is not necessarily a reason for curettage - it is possible conservative treatment within a few days. Dilation of the uterine cavity by more than 2 cm is an indication for curettage.

Placental polyps

So-called placental polyps, which are fragments of chorionic or placental tissue, fixed with a wide base on the wall of the uterine cavity, can be a very “tough nut to crack” for a sonologist. This is due to the fact that, unlike glandular polyps, placental polyps often have an irregular shape, uneven and unclear contours, difficult to differentiate from the surrounding tissues, and often simply merging with them (Fig. 14-15). According to our data, Doppler ultrasound plays an invaluable role in establishing the correct diagnosis, as it easily visualizes a powerful vascular pedicle placental polyp(Fig. 16) with a very high speed (MAC 40-100 cm/s) and very low resistance (IR 0.30-0.45), as shown in Fig. 17-18.

Perforation of the uterus

Ultrasound diagnosis of uterine perforation is made based on visualization of the uterine wall defect varying degrees expressiveness. Most often, the perforation hole is defined as a hyperechoic linear formation of small thickness (3-5 mm). In the case presented (Fig. 19-20), the perforation was complicated by an extensive hematoma (the examination was carried out several days after the perforation appeared).

Arteriovenous anomaly

Arteriovenous anomaly of the uterus for a long time was considered an extremely rare pathology. However, today we can confidently consider this opinion to be a kind of “relic of the gray-scale era.” Almost all doctors using transvaginal color Doppler ultrasonography are beginning to encounter this quite regularly. pathological condition. Arteriovenous anomaly most often appears after trophoblastic disease or complicated abortion. Based on an echographic examination, the diagnosis can only be suspected, since the echo picture is nonspecific, representing single or multiple echo-negative formations irregular shape in the thickness of the myometrium (Fig. 21). With the inclusion of a color Doppler block, the diagnosis of arteriovenous anomaly is made easily based on the visualization of a kind of “color ball” (Fig. 22-23), in the vessels of which a very high speed and low resistance of blood flow is determined (Fig. 24). Doppler monitoring often allows you to choose a conservative tactic for managing this pathology. In our practice, two cases of post-abortion arteriovenous anomalies were independently reduced within 1 and 2 months. In this case, the echostructure of the myometrium in the area of ​​interest became almost homogeneous, and the “color tangles” of arteriovenous shunts disappeared.

1. Strizhakov A.N., Davydov A.I. Shakhlamova M.N. Belotserkovtseva L.D. Ectopic pregnancy. "Medicine". Moscow. 2001.
2. Clinical guidelines for ultrasound diagnostics/ Ed. Mitkova V.V., Medvedeva M.V. T. 3. M.: Vidar, 1997.
3. Dopplerography in gynecology. Edited by Zykin B.I., Medvedev M.V. 1st edition. M. RAVUZDPG, Real Time. 2000. pp. 145-149.

Copyright © 2000-2006 "Iskra Medical Corporation", Bulanov M.N.

D abortion statistics, abortion technology, main complications of medical abortion. Tactics for managing women suspected of having residual fertilized eggs in the uterus after medical abortion. Ultrasound criteria for differentiating incomplete abortion.

Prilepskaya Vera Nikolaevna Dr. med. Sciences, prof., deputy. dir. FBGU Scientific Center of Obstetrics, Gynecology and Perinatology named after. acad. V.I.Kulakova Ministry of Health and Social Development of the Russian Federation
Gus Alexander Iosifovich Dr. med. Sciences, prof., head. department functional diagnostics FBGU Scientific Center of Obstetrics, Gynecology and Perinatology named after. acad. V.I.Kulakova Ministry of Health and Social Development of the Russian Federation
Belousov Dmitry Mikhailovich Ph.D. honey. Sciences, Associate Professor, Department of Functional Diagnostics, FBGU Scientific Center of Obstetrics, Gynecology and Perinatology named after. acad. V.I.Kulakova Ministry of Health and Social Development of the Russian Federation
Kuzemin Andrey Alexandrovich Ph.D. honey. Sciences, scientific and outpatient department of the FBGU Scientific Center of Obstetrics, Gynecology and Perinatology named after. acad. V.I.Kulakova Ministry of Health and Social Development of the Russian Federation

Summary: The article provides abortion statistics, abortion technology, and the main complications of medical abortion. The main attention is paid to the management tactics of women suspected of having residual fertilized eggs in the uterus after medical abortion. Ultrasound criteria for differentiation of incomplete abortion are indicated.

Keywords: medical abortion, ultrasound examination.

Artificial termination of pregnancy, unfortunately, continues to be one of the so-called methods of “family planning” in our country. According to official statistics, out of 10 pregnancies, only 3 end in childbirth, and 7 in abortion. In addition, every 10th abortion is performed in adolescents under 19 years of age and more than 2 thousand abortions annually in adolescents under 14 years of age.

Despite the successes achieved in Russia over the last decade in reducing the number of abortions, according to the Ministry of Health and Social Development of the Russian Federation for 2010, 1,054,820 abortions were registered, of which only 39,012 were performed using the most gentle medical method.

The relevance of the problem of abortion for Russia is also due to the fact that abortion continues to occupy a leading place in the structure of causes of maternal mortality (19.6%). Out-of-hospital abortions persist (0.09%), and the level of repeat abortions is high (29.6%). The role of abortion as a cause of gynecological morbidity and infertility is great.

It is known that termination of pregnancy poses a significant risk to health and life in general and the reproductive health of women in particular. The desire to reduce the number of abortions and working with the population in this regard is one of the main tasks of a doctor.

If we cannot currently refuse to perform induced abortions, we must at least reduce the risk of possible complications to a minimum. Therefore, the search for gentle technologies for abortion, alternative to surgical abortion, is completely obvious.

One of the safest methods of artificial termination of pregnancy is medical abortion, which has been introduced into widespread medical practice in the world since 1988, and since 1999 in our country.

Medical abortion

The term "pharmaceutical or medical abortion" means the termination of pregnancy caused by medicines. Medical abortion is an alternative to surgery.

Medical abortion provides women with additional options for ending their pregnancy and should be offered as an alternative to surgery where possible (WHO, 2000).

The method allows you to avoid complications associated with the operation: trauma, infection, negative effects of anesthesia, etc., does not require a hospital stay, is more gentle on the body and is better tolerated psychologically. Research has shown that many women prefer medical abortion to surgical abortion.

It is known that the risk of complications is reduced when pregnancy is terminated as early as possible. Medical abortion using mifepristone and prostaglandin is most effective before 6 weeks of pregnancy.

In cases where it is possible medicinal method termination of pregnancy, the vacuum aspiration method should be avoided.

Vacuum aspiration is the most appropriate technology for pregnancy beyond 6 weeks. Dilatation of the cervical canal and curettage of the uterine cavity is also an effective method of terminating pregnancy, but the least recommended due to great risk possible complications.

A successful medical abortion is defined as the complete termination of a pregnancy without the need for surgery. The effectiveness of medical abortion is 9598% per early stages pregnancy (42 days from the 1st day of the last menstruation or 6 weeks of pregnancy).

Failure of the method is possible in 2-5% of cases and depends on certain individual characteristics the woman’s body and the initial state of her health. The method is considered ineffective in cases of ongoing pregnancy, incomplete expulsion of the fertilized egg, or bleeding.

If the method is ineffective, surgical abortion is resorted to.

Gestational age

Mifepristone is used throughout the civilized world for the purpose of medical abortion.

The mifepristone regimen gives good results during pregnancy up to 6 weeks. There is evidence that at later stages the drug can also be used, but its effectiveness decreases.

Safety

Pharmacological abortion using mifepristone and misoprostol under medical supervision is safe. The drugs do not have long-term effects and do not affect the woman’s health.

The method of medical termination of pregnancy is recommended by WHO as a safe form of abortion.

Fertility

Medical abortion using mifepristone and misoprostol does not affect a woman's fertility. A woman can become pregnant already in the 1st spontaneous menstrual cycle after a pharmacological abortion, so she must use contraception.

Portability

Medical abortion is well tolerated by women. Painful sensations (similar to menstrual pain) may occur when taking prostaglandins. To remove pain analgesics can be used.

When carrying out a pharmacological abortion procedure, you need to know the following:
- Ectopic pregnancy. Medical abortion does not harm the woman's health, but does not terminate an ectopic pregnancy. Detection of the fertilized egg in the uterine cavity before a medical abortion is a prerequisite. A woman with an ectopic pregnancy requires surgical treatment.
- Teratogenic effect. There is a very low percentage of pregnancies (1-2%) that can continue to progress after taking medications that cause medical abortion. If pregnancy continues and the woman changes her decision regarding abortion, she should be warned that there is a risk of congenital pathology of the fetus. There is no evidence that mifepristone has a teratogenic effect on the fetus. However, there is evidence of the teratogenic effect of misoprostol (a prostaglandin). Although the risk of developing birth defects low enough, it is necessary to complete the abortion surgically in case of unsuccessful outcome of medical abortion.

After artificial termination of the 1st pregnancy (by any method), women with Rh-negative blood are immunized with human anti-Rh immunoglobulin in order to prevent future Rh conflict.

The indication for medical abortion is a woman's desire to terminate a pregnancy when the pregnancy is up to 6 weeks (or 42 days of amenorrhea).

In the presence of medical indications To terminate a pregnancy, medical abortion can also be used if the gestational age does not exceed the period allowed for the method.

Contraindications for medical abortion:
- Ectopic pregnancy or suspicion of it.
— Adrenal insufficiency and/or long-term corticosteroid therapy.
— Blood diseases (there is a risk of bleeding).
— Hemorrhagic disorders and anticoagulant therapy.
- Renal and liver failure.
— Large uterine fibroids or with a submucous location of the node (there is a risk of bleeding).
— The presence of intrauterine devices in the uterine cavity (it is necessary to first remove the intrauterine device, and then perform a medical abortion).
— Acute inflammatory diseases of the female genital organs (it is possible to carry out treatment simultaneously with medical abortion).
— Allergic reactions to mifepristone or misoprostol.
- Smoking more than 20 cigarettes per day in women over 35 years of age (consultation with a physician is required).
- Drugs are prescribed with caution when bronchial asthma, heavy arterial hypertension, cardiac arrhythmias and heart failure.

Criteria for assessing the effectiveness of medical abortion

A medical abortion is considered successful if the size of the uterus is normal and the patient has no pain; slight mucous-bloody discharge is possible.

Ultrasound examination (ultrasound) confirms the absence of the fertilized egg or its elements in the uterine cavity. It is very important to differentiate blood clots, fragments of the ovum from a truly incomplete abortion and ongoing pregnancy. After the death of the fetus, non-viable membranes may remain in the uterus. If an ultrasound reveals fragments of the fertilized egg in the uterine cavity, but the woman is clinically healthy, then expectant tactics are often effective, except in cases of ongoing pregnancy.

If an incomplete abortion is suspected, it is recommended, if possible, to study the level of human chorionic gonadotropin (hCG) subunit in the peripheral blood. The level of hCG in the blood serum after a successful medical abortion 2 weeks after taking mifepristone should be below 1000 mU/l. The time required to achieve a very low L-hCG level (below 50 mU/L) is directly related to its initial level. To track the dynamics of the L-hCG level, it is necessary to measure the L-hCG level before the abortion (to compare the results of successive tests). Due to the fact that L-hCG analysis is expensive and not strictly necessary, it is better to use ultrasound to diagnose complications.

Complications

As already mentioned, the effectiveness of the method is 95-98%. In case of ineffectiveness of the method, assessed on the 14th day after taking mifepristone (incomplete abortion, ongoing pregnancy), it is necessary to complete the abortion surgically (vacuum aspiration or curettage) (Fig. 1).

Bleeding. Heavy bleeding, leading to a clinically significant change in hemoglobin levels, is rarely observed. In approximately 1% of cases, it may be necessary to stop bleeding. surgical intervention(vacuum aspiration or curettage of the uterine cavity). The need for blood transfusion occurs even less frequently (0.1% of cases according to WHO).

Progressive pregnancy occurs in 0.1-1% of cases and its diagnosis is usually not difficult. The lack of effect of mifepristone may be due to the characteristics of the progesterone receptor system in some women and/or genetically determined characteristics of the liver enzyme systems that metabolize mifepristone (it was found that in such patients there is no peak concentration of mifepristone in the blood serum 1.5 hours after administration ).

When the remnants of the fertilized egg are retained in the uterine cavity, disagreements often arise in the management of patients. It must be remembered that “remnants of the fertilized egg in the uterine cavity” is a clinical diagnosis. The diagnosis is established on the basis of a general, gynecological examination and ultrasound (dilated uterine cavity more than 10 mm, heterogeneous endometrium due to hypo- and hyperechoic inclusions). The frequency of this complication depends on the length of pregnancy and the reproductive history of the woman. The longer the period at which the pregnancy is terminated, the higher the frequency of this complication. At risk for clinical diagnosis“remains of the fertilized egg in the uterine cavity” includes women whose medical history indicates the presence of chronic inflammatory diseases of the uterus and appendages.

It should be noted that heterogeneity of the endometrium and the presence of blood clots in the uterine cavity, even on the 14th day after taking mifepristone, do not always require aspiration. In the case of an unclear ultrasound picture and the absence of clinical manifestations of retained ovum remnants (pain in the lower abdomen, fever, intense bleeding), as well as during a gynecological examination (softness, soreness of the uterus), a wait-and-see approach and so-called “hormonal curettage” with progestogens (norethisterone or dydrogesterone from the 16th to 25th day from the onset of bleeding) are possible, and to prevent possible inflammatory complications, the administration of conventional antibacterial and restorative therapy. If a woman has no signs of infection, bleeding, i.e. It is possible to wait until the remaining fetal egg is completely expelled from the uterine cavity; it is advisable to prescribe an additional dose of misoprostol in order to enhance the contractile activity of the uterus.

As a rule, when assessing the state of the endometrium after the onset of menstruation, in 99% of women, according to ultrasound, a homogeneous endometrium is visualized, and only in 0.8% of women, on the 4-5th day of a menstrual-like reaction, according to ultrasound, hyperechoic structures in the uterine cavity remain, indicating the need removing remnants of the fertilized egg.

In case of incomplete abortion and retention of a detached fetal egg in the uterus, vacuum aspiration and/or instrumental revision examination of the uterine cavity with a small curette, followed by histological examination of the resulting material.

Material and research methods

The authors observed 42 women who wanted to terminate their pregnancy, average age which was 24.4±1.4 years. Unwanted pregnancy in repeat pregnant women occurred in 11 (26.2%) cases. The parity of the examined women was of the following nature: 2 (4.8%) women had 2 healthy children, the pregnancy had not been previously terminated; 1 (2.4%) patient had a history of examination for recurrent miscarriage, and subsequently gave birth to 2 healthy children; 5 (11.9%) women had 1 healthy child and have not undergone an artificial abortion; 2 (4.8%) women had previously resorted to medical termination of pregnancy without complications; 1 (2.4%) patient underwent vacuum aspiration 2 times to terminate an unwanted pregnancy. Patients with uterine fibroids and adenomyosis were excluded from the study, after caesarean section, as well as those with a history of acute inflammatory diseases of the female genital organs.

Ultrasound was performed using a Siemens Antares V 4.0 ultrasound scanner (an expert-class device) equipped with a high-frequency endovaginal sensor (5.5-11 MHz) twice: 1st time to confirm the presence of uncomplicated intrauterine pregnancy, determining the duration of pregnancy and the absence of concomitant organic pathology, 2nd on the 5-7th day after taking Mirolut (according to the generally accepted scheme) to assess the effectiveness of medical abortion.

When performing an ultrasound, the gestational age was determined using the classical method: assessment of 3 mutually perpendicular internal diameters of the fetal egg and calculation of the average, and if an embryo was detected, measurement of the coccygeal-parietal size (CPR). The presence of a heartbeat in the embryo, the thickness of the villous chorion and the presence of corpus luteum(tel) in one of the ovaries. Based on the obtained fetometric data, the gestational age was established according to the table of V.N. Demidov (1984). Patients whose CTE exceeded 7 mm (corresponding to a gestational age of 6 weeks 2 days), according to the approved medical technology “Medical abortion in early pregnancy” (2009), were excluded from the study.

In 41 (97.6%) women, 1 fertilized egg was found in the uterine cavity. Dichorionic twins were identified in 1 (2.4%) patient. (It should be noted that this pregnant woman was taking combination oral contraceptives for 3 years continuously, pregnancy occurred during drug withdrawal.)

The average gestational age was 5.1±0.6 weeks, the thickness of the villous chorion was 5.0±0.1 mm (Fig. 2). Corpus luteum were detected in 2 ovaries with almost equal frequency: in the right in 18 (42.8%) women, in the left in 24 (57.1%), respectively. The average diameter of the corpus luteum was 18.6±2.7 mm. In 2 (4.8%) pregnant women, the course of the first trimester was accompanied by the formation of retrochorial hematomas small sizes without clinical manifestations, which was revealed only by ultrasound (Fig. 3).

Repeated ultrasound screening was carried out on the 10-13th day from the onset of bleeding from the genital tract (this daily interval is due to calendar days off).

The course of the period after taking misoprostol in most cases was similar: on days 10-13, bleeding was scanty in 36 (85.7%), abundant in 4 (9.5%), and 2 (4.8%). ) patients these discharges were absent. During ultrasound screening Special attention paid attention to the condition of the uterine cavity: expansion of the uterine cavity due to liquid blood with clots was noted in 36 (85.7%) women on average up to 4.2 ± 1.4 mm, while the thickness of the median M-echo was 10.1 ± 1, 6 mm, the endometrium had clear boundaries and structurally corresponded to the late proliferative phase (Fig. 4). In 6 (14.3%) patients there was a significant (16.7±3.3 mm) expansion of the uterine cavity due to acoustically dense structures. These patients underwent additional examination. The authors carried out color Doppler mapping of the “problem area”. In 5 (11.9%) patients, pronounced hematometra phenomena were not accompanied by signs of active vascularization of the uterine contents. On the contrary, in 1 (2.4%) patient, in whom the authors suspected an incomplete abortion, the “problem area” had active vascularization with low-resistance (resistance index 0.42) arterial blood flow.

The greatest interest was attracted to patients with significant dilation of the uterine cavity, in whom, according to ultrasound data, incomplete emptying of the uterine cavity was suspected (Fig. 5). For women with significant dilation of the uterine cavity, it was decided to analyze L-hCG in the blood serum, where trace amounts of this substance were noted. A wait-and-see approach was chosen: after the end of menstruation, which occurred in the form of heavy discharge from the genital tract with the passage of dense blood clots on the 1st day, a control ultrasound was performed, which revealed no significant features of the condition of the uterine cavity.

Increased for this period after termination of pregnancy L-hCG level 223 IU/ml was present in 1 patient with signs of active vascularization of the contents of the uterine cavity (Fig. 6). Taking into account the examination data, it was decided to carry out vacuum aspiration of the uterine cavity, followed by a histological analysis of the resulting material, where fragments of chorionic tissue were found, as well as the phenomenon of lymphoid infiltration of the tissue.

Discussion of the results obtained

Analysis of the study indicates the high effectiveness of abortion with the drug mifepristone: a positive result was obtained in 97.6% of cases. When studying the anamnesis and clinical situation of a patient with remnants of the ovum, it was noted that this patient was observed under the program of recurrent miscarriage and was subjected to double curettage of the uterine cavity due to a non-developing short-term pregnancy. The presence of lymphoid infiltration of the contents of the uterine cavity may indicate the presence of sluggish chronic endometritis Ultimately, these factors could lead to the retention of fragments of the fertilized egg in the uterine cavity.

It should be noted that in order to exclude unjustified surgical measures, it is necessary to approach the issue of assessing the condition of the uterine cavity after medical termination of pregnancy with special responsibility. It is necessary to take into account that, unlike surgical abortion, after the use of antiprogestins, blood clots, fragments of chorionic tissue and endometrium always accumulate in the uterine cavity.

Expansion of the uterine cavity, sometimes even significant, does not always indicate an incomplete abortion. Only the combination of pathology detected by ultrasound, an increased level of serum hCG, as well as active low-resistant vascularization of the contents of the uterine cavity should suggest the remains of a fetal egg in the uterine cavity. The presence of hematometra in the absence of accompanying signs should not serve as an indication for urgent surgical intervention, but requires expectant management and further ultrasound monitoring, and only if clinical and ultrasound signs of blood accumulation in the uterine cavity persist, surgical tactics (vacuum aspiration) are appropriate.

Advantages of medical termination of early pregnancy using mifepristone and misoprostol:
— High efficiency method, reaching 95-98.6% and confirmed by clinical research data.
— The safety of the method due to:

• low percentage of complications (see chapter “Complications”. Possible complications progressive pregnancy, retained ovum, bleeding are treated traditional method vacuum aspiration of the contents of the uterine cavity);
• no risk associated with anesthesia;
• no risk of complications associated with the surgery itself: mechanical damage endo-myometrium, trauma to the cervical canal, risk of uterine perforation;
• eliminating the danger of ascending infection and associated complications during surgical intervention, since the “obturator” apparatus of the cervical canal is not damaged and there is no penetration of instruments into the uterine cavity;
• excluding the danger of transmission of HIV infection, hepatitis B and C, etc.;
• absence of long-term adverse effects on reproductive function.

High acceptability of medical abortion:
— The drug is well tolerated by patients.
— A sociological survey showed high satisfaction with the method and the right of choice given to the patient.

When using the so-called tablet abortion, there is no such pronounced psychogenic trauma as with surgical termination of pregnancy (it is difficult for the patient to decide on surgical intervention, psychologically endure the abortion, etc.), the listed advantages are especially important for primigravidas, for whom mifepristone is the drug of choice for termination unwanted pregnancy.

conclusions

— The effectiveness of misoprostol in our study was 97.6%.

— According to ultrasound data, up to 11.9% of cases were interpreted as incomplete abortion, however, when examined after 1 month, these patients did not require surgical revision of the uterine cavity.

— Clear criteria for vacuum aspiration of the contents of the uterine cavity after medical termination of pregnancy according to ultrasound monitoring are pronounced expansion of the uterine cavity with heterogeneous contents (more than 20 mm in the middle 1/3 of the uterine cavity), active vascularization of this content (arterial type of hemodynamics) and increased serum levels b-hCG.

— Minor changes detected by ultrasound on the 7-12th day after starting misoprostol (moderate hematometra and deciduometra) and the absence of negative dynamics of the condition of the uterine cavity after the 1st menstruation during medical termination of pregnancy do not require active surgical tactics in such patients . Dynamic clinical and ultrasound monitoring is recommended.

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