Pyrohova V. I.
Doctor of Medical Sciences, professor,
Head of the Department of Obstetrics, Gynecology and Perinatology
Lviv National Medical University named after Danylo Halitskyy
Oshurkevich O. O.
PhD Student of the Department of Obstetrics,
Gynecology, and Perinatology
Lviv National Medical University named after Danylo Halitskyy
Пирогова Вера Ивановна,
Д. мед. наук, профессор, заведующая кафедрой акушерства,
гинекологии и перинатологии
Львовский национальный медицинский
университет имени Данила Галицкого
Ошуркевич Оксана Орестовна,
соискатель кафедры акушерства, гинекологии
ФПДО Львовский национальный медицинский
университет имени Данила Галицкого
EVALUATION OF RISK FACTORS AND EFFICACY THREATS
MISCARRIAGE, COMPLICATED BY A RETROCHORIAL HEMATOMAS
ОЦЕНКА ФАКТОРОВ РИСКА И ЭФФЕКТИВНОСТИ ТЕРАПИИ УГРОЗЫ НЕВЫНАШИВАНИЯ БЕРЕМЕННОСТИ, ОСЛОЖНЕННОЙ РЕТРОХОРИАЛЬНОЙ ГЕМАТОМОЙ
Summary: Based on a set of examinations, an assessment of risk factors and the effectiveness of treatment of the threat of miscarriage complicated by retrochorial hematoma was carried out. Risk factors for the development of retrochorial hematomas in the first trimester are previous early pregnancy losses in history, curettage of the uterus due to artifactual, spontaneous abortions and non-developing pregnancy, cesarean section, inflammatory pathology of the cervix. The identified factors significantly increase the risk of developing retrochorial hematoma by a factor of 2 or more when a pregnancy occurs. The importance of echographic control in the treatment process for the correction of therapy is shown. It has been proven that the use of sublingual form of micronized progesterone gives a pronounced therapeutic effect (95.4% of prolonged pregnancies) in patients with recurrent miscarriage, a pronounced clinical picture of threatened abortion and the presence of retrochorial hematoma.
Key words: miscarriage, retrochorial hematoma, micronized progesterone
Аннотация: На основании комплекса обследований проведена оценка факторов риска и эффективности терапии угрозы невынашивания беременности, осложненной ретрохориальной гематомой. Факторами риска развития ретрохориальных гематом в I триместре являются предшествующие ранние потери беременности в анамнезе, выскабливание полости матки по поводу артифициальных, самопроизвольных абортов и неразвивающейся беременности, операция кесарева сечения, воспалительная патология шейки матки. Выявленные факторы достоверно увеличивают риск развития ретрохориальной гематомы в 2 и более раз при возникновении беременности. Показано важность эхографического контроля в процессе лечения для коррекции терапии. Доказано, что применение сублингвальной формы микронизированного прогестерона дает выраженный терапевтический эффект (95,4 % пролонгированных беременностей) у пациенток с привычным невынашиванием, выраженной клинической картиной угрозы прерывания и наличием ретрохориальной гематомы.
Ключевые слова: невынашивание беременности, ретрохориальная гематома, микронизированный прогестерон
Formulation of the problem. Miscarriage as the most important general medical and social problem is under the constant attention of the leading scientific schools of the world [4, 9]. The first trimester of pregnancy is the most significant, since it is during this period that embryogenesis occurs, the formation of the placenta and the establishment of a complex relationship between the mother and the foetus. The threat of termination of pregnancy in the first trimester hinders the normal course of these processes, and vaginal bleeding is one of the most common complications of gestation [1, 8].
Significantly worsens the chances of a successful completion of pregnancy, the development of retrochorial hematoma. Retrochorial hematoma is considered as a specific pathological condition, usually arising in the first trimester of pregnancy, manifested as haemorrhage and accumulation of blood (hematoma) in the subhorial (retrochorial) space. Retrochorial hematoma is one of the most common findings with ultrasound, especially in patients with bleeding in early pregnancy, accounting for about 18% of all cases of bleeding in the first trimester [4, 7].
The frequency of hematomas in the first trimester of pregnancy, diagnosed by ultrasound, varies from 4 to 22% depending on the patient population studied, whereas in the total obstetric population it varies from 1.3 to 3.1%. There are no specific signs of retrochorial hematoma and can be diagnosed only on the basis of ultrasound scan data. The etiology of the occurrence of retrochorial hematomas is currently not fully understood [1, 2, and 10].
Analysis of recent research and publications.
Diagnosis of retrochorial hematoma is based on a comparison of clinical examination data with the results of ultrasound diagnosis. Symptoms of threatening miscarriage, such as bleeding or spotting blood from the genital tract, cramping pain in the lower abdomen, are observed in the vast majority of patients (71%). Partial detachment of the chorion is often accompanied by a clinic threatening miscarriage, but may be an accidental finding during an ultrasound examination.
In accordance with the dimensions determined by ultrasound, it is customary to regard the retrochorial hematoma as small if its size is less than 20% of the size of the gestational egg, medium sizes in the case of 20-50% and massive if it exceeds 50% of the size of the gestational egg [5, 6]. From 8.9% to 23.78% of pregnancies with the retrochorial hematoma ends in miscarriage [9, 10]. The detachment site excludes part of the chorionic villi from the microcirculation zone, which leads to impaired uteroplacental circulation [3, 5, and 11]. Treatment of patients with the threat of interruption amid partial detachment of the ovum contributes to prolongation of pregnancy, but does not prevent the formation and progression of placental insufficiency and the risk of obstetric and perinatal problems .
In the case of prolongation of pregnancy, the risk of developing maternal and neonatal complications increases: premature birth, intrauterine growth retardation, placental abruption, preeclampsia and others .
Isolation of previously unsolved parts of a common problem.
Theoretically, the amount of hematoma should affect the prognosis of pregnancy. However, existing opinions about the clinical significance of intrauterine hematomas are controversial. A number of authors are trying to correlate hematoma size directly with pregnancy outcomes and determine whether this factor has prognostic value. At the same time, a number of authors did not find a relationship between the incidence of miscarriage and the size of the hematoma, that is, the volume of the hematoma does not correlate with pregnancy outcomes [1, 9, and 10]. In a number of studies, no statistically significant relationship has been obtained between the gestational age at the time of diagnosis, the size of the hematoma, its location and the outcome of pregnancy (the frequency of miscarriages and premature births).
Despite a wide discussion of the clinical significance of retrochorial hematoma, the risk factors for its development are described in individual works, and there is no unanimous opinion on this issue among researchers. As risk factors, inflammatory diseases of the pelvic organs, dysmenorrhea, cervical ectopia, intrauterine devices, previous pregnancy losses are discussed . The high risk of development of complications during the course of pregnancy, its unfavourable outcome determines the search for effective approaches to the treatment of the threat of miscarriage, especially with the development of retrochorial hematomas.
If the embryo (foetus) does not die, then development of placental insufficiency is possible in 24% of cases, premature birth — in 16-19% (of which 43% within less than 34 weeks), pre-eclampsia — in 8%, delayed foetal development — in 7%, distress syndrome in a newborn — in 19%. The frequency of caesarean section in this group of pregnant women is 27%.
The purpose of the study — analysis of the clinical significance and effectiveness of the treatment of miscarriage associated with retrochorial hematoma.
The presentation of the main material.
A total of 165 patients with threatened abortion who were hospitalized in the emergency gynaecology department took part in the study: 65 pregnant women with retrochorial hematoma detected from 6 to 12 weeks made up the main group, 50 women with threatened abortion without retrochorial hematoma made up the group comparisons. The control group consisted of 50 conditionally healthy pregnant women in the same period of gestation observed in the antenatal clinic. The average age of the main group of pregnant women was 26.5 ± 4.2 years, the comparison group — 27.1 ± 1.4 years of the control group — 27.3 ± 3.4 years.
The obstetric and gynaecological history was analyzed: the number of pregnancies, parity, previous early pregnancy losses, intrauterine interventions, surgical interventions (caesarean section, other operations on the pelvic organs). A comprehensive clinical and laboratory examination included a clinical analysis of blood and urine, determination of blood group and Rh factor, biochemical analysis of blood, coagulation, serological screening for perinatal infections, determination of the state of the vaginal microbiota, diagnosis of antiphospholipid syndrome, thyroid gland pathology. Statistical processing of the material was performed using the Microsoft Excel and Statistica 6.0 for Windows application software package, following the recommendations for medical and biological research.
Ultrasound examination was performed on the Acuson x150, Siemens apparatus with assessment of the coccyx parietal size, embryo heart rate, yolk sac condition and size, chorion localization, its location, structure, structural features of the uterine walls and appendages; estimated the size, volume of retrochorial hematoma, its localization, stage of development. According to localization, the hematoma was classified as a corporal and supracervical, according to the developmental stages, an organized, with signs of organization and an unorganized retrochorial hematoma were identified.
Upon admission to the hospital, complaints of bleeding from the vagina were presented by 53 (81.5%) patients of the main group and 5 (10.0%) — the comparison group; for lower abdominal pain — 23 (43.4%) and 45 (90.0%), respectively. In the main group, 12 (18.5%) pregnant women had no complaints in the presence of a corporally located retrochorial hematoma.
A statistically significant difference (p <0.05) was found between the number of adverse outcomes of pregnancies in history in patients with retrochorial hematoma and in the control group. A spontaneous abortion in history, undeveloped pregnancy, inflammatory pathology of the cervix, dyshormonal pathology significantly more frequently observed in patients of the main group. In the study of history, we reviewed in detail the data on transferred gynaecological diseases. Scraping of the uterus, caused by the pathology of the endometrium, spontaneous abortion, non-developing pregnancy, artificial abortion (p = 0.0489) was more often observed in patients with retrochorial hematoma compared with patients in the control group.
Multifactor analysis showed that even one of the listed anamnesis’ factors: previous early reproductive losses, caesarean section, curettage of the uterus, intrauterine interventions, caused an increased risk of retrochorial hematoma during the time of pregnancy at the time of the study 2 times or more (from 2, 12 to 7.24 times).
An ultrasound study carried out at the time of admission to the hospital resulted in 65 pregnant women (main group) with retrochorial hematoma. The structure of the retrochorial hematoma before the start of therapy in 58 (89.2%) pregnant women had no signs of organization and was an anechoic formation. In 40 (61.5%) women, retrochorial hematoma was located corporally, in 25 (38.5%) — supracervical. The volume of hematomas ranged from 1.6 to 39.1 cm3, in 5 (7.7%) cases exceeded 40% of the volume of the ovum. The volumes of the chorial and amniotic cavities corresponded to the gestation period in the majority of pregnant women of both groups, and only 12 (18.5%) pregnant women of the main group and 7 (14.0%) of the comparison group detected amnion hypoplasia.
Deformation of the gestational egg was detected in the main group in 12 (18.5%) cases, and in 7 (10.8%) women, the low position of the gestational egg was observed. Hypertonus of myometrium of various degrees was determined in 45 (69.2%) women of the main group, and 45 (90.0%) — the comparison group. In 5 (10.0%) pregnant comparison groups, in the presence of bloody vaginal discharge, retrochorial hematoma was not detected by ultrasound, in some patients, relative signs of threatened pregnancy were detected — no yellow body cyst up to 12 weeks of pregnancy in 23 (35.4%) in the main group and 17 (34.0%) in the comparison group, premature reduction of the yolk sac in 7 (10.8%) and 7 (14.0%), respectively.
In the main group, all patients received sublingual micronized progesterone 100 mg 4 times a day for 7 days with the aim of treating a threatening miscarriage, followed by dose reduction taking into account the clinical picture, echography data and laboratory values up to 50 mg three times a day or translated into Intravaginal administration of micronized progesterone 100 mg twice a day. In parallel, patients with hemostatic purpose received tranexamic acid 500 mg three times a day for 7 days, iodomarin 200 μg / day, cholecalciferol 4000 MO / day. Pregnant comparison groups received similar therapy with the exception of tranexamic acid.
Parameters of the retrochorial hematoma were assessed on the day of admission to inpatient treatment, on the 7th and 14th days of treatment and on the 21st day after the start of treatment (in the hospital if it is necessary to continue treatment or on an outpatient basis after the patient’s discharge).
According to the obtained results, retrochorial hematoma tended to decrease already after 7 days from the start of treatment. After 14 days, there was a significant (p = 0.023) decrease in the volume of retrochorial hematoma in 53 (81.5%), in 6 (9.2%) patients, the total absence of visualization of the hematoma. After 24 days, the majority of patients (62 — 95.4%) of the main group and the comparison group (48 — 96.0%) did not show signs of threatened abortion during an ultrasound study, and 23 (35.4%) patients had in place of hematomas heterogeneous structure, up to a maximum of 1.5 ml in volume. The total lack of visualization of the retrochorial hematoma was found in 60 (92.3%) after 29.5 ± 5.3 days.
A spontaneous abortion ended pregnancy in 3 (4.6%) women with large corporal hematoma. Relapse of retrochorial hematoma at 17-18 weeks of gestation occurred in 2 (3.2%) patients of the main group.
- Risk factors for the development of retrochorial hematomas in the first trimester are previous early pregnancy losses in history, curettage of the uterus due to artificial, spontaneous abortions and non-developing pregnancy, caesarean section, inflammatory pathology of the cervix. The identified factors significantly increase the risk of developing retrochorial hematoma by a factor of 2 or more when a pregnancy occurs.
- When a retrochorial hematoma is detected, an echographic control should be carried out during treatment and the treatment should be corrected to take into account the main ultrasound signs of threatened abortion.
- The use of sublingual form of micronized progesterone showed a pronounced therapeutic effect in treating the threat of spontaneous abortion in the first trimester, which undoubtedly must be taken into account when prescribing progesterone drugs in combination therapy for preserving pregnancy, especially in patients with a habitual miscarriage, pronounced clinical picture of the threat of interruption and in the presence of retrochorial hematoma.
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