Miscarriage is common, causes, treatment, prevention, risk. Modern problems of science and education Premature pregnancy

According to statistics, miscarriage is recorded in 10-25% of pregnant women.

The cause of miscarriage can be various diseases that are difficult to cure or become chronic. Moreover, these diseases do not belong to the genital area. An important feature of this kind of pathology is the unpredictability of the process, since for each particular pregnancy it is difficult to determine the true reason for the termination of pregnancy. Indeed, at the same time, many different factors affect the body of a pregnant woman, which can act covertly or explicitly. The outcome of pregnancy in the case of her habitual miscarriage is largely determined by the therapy. With three or more spontaneous miscarriages during pregnancy up to 20 weeks of pregnancy, the obstetrician-gynecologist diagnoses recurrent miscarriage. This pathology occurs in 1% of all pregnant women.

After the fertilized egg has "settled" in the uterine cavity, the complex process of its engraftment begins there - implantation. The future baby first develops from the ovum, then becomes an embryo, then it is called the fetus, which grows and develops during pregnancy. Unfortunately, at any stage of carrying a child, a woman may face such a pathology of pregnancy as miscarriage.

Miscarriage is the termination of pregnancy from the moment of conception to the 37th week.

Risk of primary miscarriage

Doctors note a certain pattern: the risk of spontaneous abortion after two failures increases by 24%, after three - 30%, after four - 40%.

With miscarriage, a complete or incomplete pregnancy occurs (the ovum detached from the wall of the uterus, but remained in its cavity and did not come out), a miscarriage in the period up to 22 weeks. At a later date, in the period 22-37 weeks, spontaneous termination of pregnancy is called premature birth, while an immature but viable baby is born. Its weight ranges from 500 to 2500 g. Premature, prematurely born children are immature. Their death is often noted. Developmental malformations are often recorded in surviving children. The concept of prematurity, in addition to the short term for the development of pregnancy, includes a low fetal body weight at birth, on average from 500 to 2500 g, as well as signs of physical immaturity in the fetus. Only by the combination of these three signs, a newborn can be considered premature.

With the development of miscarriage, certain risk factors are indicated.

Modern advances in medicine and new technologies, timeliness and quality of medical care make it possible to avoid serious complications and prevent premature termination of pregnancy.

A woman with a first trimester miscarriage should undergo a long examination even before the intended pregnancy and during pregnancy to identify the true cause of miscarriage. A very difficult situation develops with spontaneous miscarriage against the background of the normal course of pregnancy. In such cases, the woman and her doctor can do nothing to prevent such a course of events.

The most common factor in the development of premature termination of pregnancy is fetal chromosomal abnormalities. Chromosomes are microscopic elongated structures located in the internal structure of cells. Chromosomes contain genetic material that sets all the properties characteristic of each "person: eye color, hair, height, weight parameters, etc. In the structure of the human genetic code there are 23 pairs of chromosomes, in total 46, with one part inherited from organism, and the second - from the father. Two chromosomes in each set are called sex and determine the sex of a person (XX chromosomes determine the female sex, XY chromosomes - the male sex), while the other chromosomes carry the rest of the genetic information about the whole organism and are called somatic.

It was found that about 70% of all miscarriages in early pregnancy are due to abnormalities of somatic chromosomes in the fetus, while most of the chromosomal abnormalities of the developing fetus were due to the participation of a defective egg or sperm in the fertilization process. This is due to the biological process of division, when an egg and a sperm cell during their pre-maturation divide in order to form mature germ cells, in which the set of chromosomes is 23. In other cases, eggs or spermatozoa with an insufficient (22) or with an excess (24) set are formed. chromosomes. In such cases, the formed embryo will develop with a chromosomal abnormality, which leads to a miscarriage.

The most common chromosomal defect can be considered trisomy, while the embryo is formed when the germ cell merges with chromosome set 24, as a result of which the set of fetal chromosomes is not 46 (23 + 23), as it should be normal, but 47 (24 + 23) chromosomes ... Most trisomies involving somatic chromosomes lead to the development of a fetus with defects that are incompatible with life, which is why spontaneous miscarriage occurs in the early stages of pregnancy. In rare cases, a fetus with a similar developmental anomaly survives to a long time.

Down's disease (represented by trisomy 21 on chromosome) can be cited as an example of the most well-known developmental abnormality caused by trisomy.

A large role in the occurrence of chromosomal abnormalities is played by the woman's age. And recent studies show that the age of the father plays an equally important role, the risk of genetic abnormalities increases when the father is over 40 years old.
As a solution to this problem, married couples where at least one partner has been diagnosed with congenital genetic diseases is offered mandatory counseling with a geneticist. In certain cases, IVF is proposed (in vitro fertilization - in vitro fertilization) with a donor egg or sperm, which directly depends on which of the partners has revealed such chromosomal abnormalities.

Causes of primary miscarriage

There can be many reasons for the occurrence of such violations. The process of conceiving and bearing a baby is complex and fragile, it involves a large number of interrelated factors, one of which is endocrine (hormonal). The female body maintains a certain hormonal background so that the baby can develop correctly at every stage of its intrauterine development. If, for some reason, the body of the expectant mother begins to produce hormones incorrectly, then hormonal imbalances threaten to terminate the pregnancy.

Never take hormones on your own. Taking them can seriously impair reproductive function.

The following congenital or acquired uterine lesions may threaten the course of pregnancy.

• Anatomical malformations of the uterus - doubling of the uterus, saddle uterus, two-horned uterus, one-horned uterus, partial or complete uterine septum in the cavity - are congenital. Most often, they prevent the ovum from successfully implanting (for example, the egg "sits" on the septum, which is unable to perform the functions of the inner layer of the uterus), which is why a miscarriage occurs.
• Chronic endometritis - inflammation of the mucous layer of the uterus - the endometrium. As you remember from the section that provides information on the anatomy and physiology of women, the endometrium has an important reproductive function, but only as long as it is "healthy". Prolonged inflammation changes the nature of the mucous layer and disrupts its functionality. It will not be easy for the ovum to attach and grow and develop normally on such an endometrium, which can lead to the loss of pregnancy.
• Polyps and endometrial hyperplasia - proliferation of the mucous membrane of the uterine cavity - the endometrium. This pathology can also interfere with embryo implantation.
• Intrauterine synechiae are adhesions between the walls in the uterine cavity, which prevent the fertilized egg from moving, implanting and developing. Synechiae most often occur as a result of mechanical trauma to the uterine cavity or inflammatory diseases.
• Uterine fibroids are benign tumor processes that occur in the muscular layer of the uterus - myometrium. Fibroids can cause miscarriage if the ovum is implanted next to the myoma node, which has violated the tissue of the inner cavity of the uterus, "takes over" the blood flow and can grow towards the ovum.
• Isthmico-cervical insufficiency. It is considered the most common cause of perinatal losses in the second trimester of pregnancy (13-20%). The cervix is ​​shortened with subsequent dilatation, which leads to the loss of pregnancy. Usually, isthmic-cervical insufficiency occurs in women whose cervix has been damaged earlier (abortion, rupture in childbirth, etc.), has a congenital malformation or cannot cope with increased stress during pregnancy (large fetus, polyhydramnios, multiple pregnancies, etc.). NS.).

Some women have a congenital predisposition to thrombosis (blood clots, blood clots in the vessels), which makes it difficult to implant the ovum and interferes with normal blood flow between the placenta, baby and mother.

The expectant mother often does not even know about her pathology before pregnancy, since her hemostasis system coped well with its functions before pregnancy, that is, without the "double" load that appears with the task of carrying a baby.

There are other causes of miscarriage that need to be diagnosed for timely prevention and treatment. Correction methods will depend on the identified cause.

The reason for the habitual miscarriage can also be normal chromosomes, which do not give development problems in both partners, but carry a latent carriage of chromosomal abnormalities, which affect fetal abnormalities. In such a situation, both parents must perform a karyotype test of their blood in order to detect such chromosomal abnormalities (carriage of non-manifest chromosomal abnormalities). With this examination, based on the results of karyotyping, a probable assessment of the course of subsequent pregnancy is determined, and the examination cannot give a 100% guarantee of possible anomalies.

Chromosomal abnormalities are manifold, they can also cause missed pregnancies. In this case, only the fetal membranes are formed, while the fetus itself may not be. It is noted that the ovum is either formed initially, or it stopped its further development in the early stages. For this, in the early stages, the cessation of the characteristic symptoms of pregnancy is characteristic, at the same time, dark brown discharge from the vagina often appears. An ultrasound scan allows to reliably determine the absence of the ovum.

Miscarriage in the second trimester of pregnancy is mainly associated with abnormalities in the structure of the uterus (such as an irregular shape of the uterus, an extra uterine horn, its saddle shape, the presence of a septum, or a weakening of the retention capacity of the cervix, the disclosure of which leads to premature birth). In this case, infection of the mother (inflammatory diseases of the appendages and uterus) or chromosomal abnormalities of the fetus can become possible causes of miscarriage in the late stages. According to statistics, chromosomal abnormalities are the cause of miscarriage in the second trimester of pregnancy in 20% of cases.

Symptoms and signs of primary miscarriage

Bleeding is a characteristic symptom of miscarriage. Bloody vaginal discharge with spontaneous miscarriage usually begins suddenly. In some cases, a miscarriage is preceded by a pulling pain in the lower abdomen, which resembles pain before menstruation. Along with the release of blood from the genital tract, with the onset of spontaneous miscarriage, the following symptoms are often observed: general weakness, malaise, fever, decrease in nausea that was present before, emotional tension.

But not all cases of bleeding in early pregnancy end in spontaneous miscarriage. In case of discharge of blood from the vagina, a woman should consult a doctor. Only a doctor will be able to conduct a proper examination, determine the condition of the fetus, find out if the cervix is ​​dilated and choose the right treatment aimed at maintaining the pregnancy.

If spotting from the genital tract is detected in the hospital, a vaginal examination is performed first. If the first miscarriage occurred in the first trimester of pregnancy, then the study is carried out shallowly. In the event of a miscarriage in the second trimester or two or more spontaneous abortions in the first trimester of pregnancy, a complete examination becomes necessary.

In this case, the course of a full examination includes a certain set of examinations:

1. blood tests for chromosomal abnormalities in both parents (clarification of the karyotype) and determination of hormonal and immunological changes in the mother's blood;
2. conducting a test for chromosomal abnormalities of aborted tissues (it is possible to determine when these tissues are available - either the woman herself saved them, or they were removed after curettage of the uterus in a hospital);
3. ultrasound examination of the uterus and hysteroscopy (examination of the uterine cavity using a video camera, which is inserted through the cervix and displays a picture on the screen);
4. hysterosalpingography (x-ray examination of the uterus;
5. biopsy of the endometrium (inner layer) of the uterus. This manipulation involves taking a small piece of the uterine lining, after which a hormonal examination of the tissue is performed.

Treatment and prevention of primary miscarriage

If pregnancy is threatened by endocrine disorders in a woman, then after laboratory tests, the doctor prescribes hormonal therapy. In order to prevent unwanted hormone surges, medications can be prescribed even before pregnancy, with subsequent dosage and drug adjustments already during pregnancy. In the case of hormone therapy, the condition of the expectant mother is always monitored and the appropriate laboratory tests (analyzes) are performed.

If miscarriage is due to uterine factors, then the appropriate treatment is carried out several months before the conception of the baby, since it requires surgical intervention. During the operation, synechiae are dissected, polyps of the uterine cavity are eliminated, fibroids that interfere with the course of pregnancy are removed. Medication before pregnancy treats infections that contribute to the development of endometritis. Cervical insufficiency during pregnancy is corrected surgically. Most often, the doctor prescribes suturing of the cervix (for a period of 13-27 weeks) when its insufficiency occurs - the cervix begins to shorten, become softer, the internal or external pharynx opens. Stitches are removed at 37 weeks of gestation. A woman with a sutured cervix is ​​shown a gentle physical regimen, no psychological stress, since even on the sutured cervix, amniotic fluid may leak.

In addition to suturing the cervix, a less traumatic intervention is used - putting on a Meyer ring (obstetric pessary) on the cervix, which also protects the cervix from further disclosure.

The doctor will suggest the most appropriate method for each specific situation.

Do not forget that not only ultrasound data are important, but also information obtained during a vaginal examination, since the neck can be not only shortened, but also softened.

For the prevention and treatment of problems associated with the hemostasis system of the expectant mother, the doctor will prescribe laboratory blood tests (mutations in the hemostasis system, coagulogram, D-dimer, etc.). Based on the published examination results, medication (tablets, injections) can be applied to improve blood flow. Expectant mothers with impaired venous blood flow are recommended to wear medical compression hosiery.

There can be many reasons for miscarriage. We did not mention severe extragenital pathologies (diseases not related to the genital area), in which it is difficult to bear a child. It is possible that for a particular woman, not one reason is "working" for her condition, but several factors at once, which, overlapping each other, give such a pathology.

It is very important that a woman with miscarriage (three or more losses in history) is examined and medication trained BEFORE the forthcoming pregnancy in order to avoid this complication.

Treatment of such a pathology is extremely difficult and requires a strictly individual approach.

Most women do not need treatment as such immediately after a spontaneous miscarriage in the early stages. The uterus is gradually and completely self-cleaning, as it does during menstruation. However, in some cases of incomplete miscarriage (partially the remnants of the ovum remain in the uterine cavity) and when the cervix is ​​bent, it becomes necessary to scrap the uterine cavity. Such manipulation is also required with intense and non-stopping bleeding, as well as in cases of a threat of the development of an infectious process, or if, according to ultrasound data, remnants of the membranes are found in the uterus.

Anomalies in the structure of the uterus are one of the main causes of habitual miscarriage (the cause is in 10-15% of cases of repeated miscarriage in both the first and second trimesters of pregnancy). Such structural anomalies include: an irregular shape of the uterus, the presence of a septum in the uterine cavity, benign neoplasms that deform the uterine cavity (fibroids, fibromas, fibroids) or scars from previous surgical interventions (cesarean section, removal of fibromatous nodes). As a result of such violations, problems arise for the growth and development of the fetus. The solution in such cases is the elimination of possible structural abnormalities and very close monitoring during pregnancy.

An equally important role in the habitual miscarriage is played by a certain weakness of the muscular ring of the cervix, while the most typical term for termination of pregnancy for this reason is 16-18 weeks of pregnancy. Initially, the weakness of the muscle ring of the cervix can be congenital, and can also result from medical interventions - traumatic injuries of the muscle ring of the cervix (as a result of abortion, cleansing, rupture of the cervix during childbirth) or a certain kind of hormonal disorders (in particular, an increase in the level of male sex hormones). The problem can be solved by placing a special suture around the cervix at the beginning of the subsequent pregnancy. The procedure is called "cervical sequestration".

A significant cause of recurrent miscarriage is hormonal imbalance. Thus, the studies conducted have revealed that a low level of progesterone is extremely important in maintaining pregnancy in the early stages. It is the lack of this hormone that is the cause of early termination of pregnancy in 40% of cases. The modern pharmaceutical market has significantly replenished with drugs similar to the hormone progesterone. These are called progestins. The molecules of such synthetic substances are very similar to progesterone, but they also have a number of differences due to modification. Such drugs are used in hormone replacement therapy in cases of insufficiency of the corpus luteum, although each of them has a certain range of disadvantages and side effects. Currently, one can name only one drug that is completely identical to natural progesterone - utrozhestan. The drug is very easy to use - it can be taken orally and inserted into the vagina. Moreover, the vaginal route of administration has a large number of advantages, since, being absorbed into the vagina, progesterone immediately enters the uterine bloodstream, therefore, the secretion of progesterone by the corpus luteum is simulated. To maintain the luteal phase, micronized progesterone is prescribed in a dose of 2-3 capsules per day. If, against the background of the use of urozhestan, pregnancy develops safely, then its reception continues, and the dose is increased to 10 capsules (as determined by the gynecologist). With the course of pregnancy, the dosage of the drug is gradually reduced. The drug is reasonably used up to the 20th week of pregnancy.

Severe hormonal disturbance can be a consequence of polycystic ovaries, resulting in multiple cystic formations in the body of the ovaries. The reasons for repeated failure in such cases are not well understood. Habitual miscarriage is often the result of immune disorders in the body of the mother and fetus. This is due to the specific feature of the body to produce antibodies to fight off penetrating infections. However, the body can also synthesize antibodies against the body's own cells (autoantibodies), which can attack the body's own tissues, causing health problems and premature termination of pregnancy. These autoimmune disorders are the cause in 3-15% of cases of habitual pregnancy failure. In such a situation, first of all, it is necessary to measure the available level of antibodies with the help of special blood tests. Treatment involves the use of low doses of aspirin and blood thinners (heparin), which leads to the possibility of carrying a healthy baby.

Modern medicine draws attention to a new genetic abnormality - factor V Leiden mutation, which affects blood clotting. This genetic trait can also play an important role in recurrent miscarriage. Treatment of this kind of disorders is currently not fully developed.

A special place among the causes of habitual pregnancy failure is occupied by asymptomatic infectious processes in the genitals. It is possible to prevent premature termination of pregnancy by routine examination of partners for infections, including women, before a planned pregnancy. The main pathogens causing recurrent miscarriage are mycoplasmas and ureaplasmas. For the treatment of such infections, antibiotics are used: ofloxin, vibromycin, doxycycline. Treatment must be performed by both partners. A control examination for the presence of these pathogens is performed one month after the end of antibiotic therapy. A combination of local and general treatment is essential in this case. Locally, it is better to use broad-spectrum drugs that act on several pathogens at the same time.

In the event that the reasons for repeated pregnancy failure even after a comprehensive examination cannot be found, the spouses should not lose hope. It was statistically established that in 65% of cases after pregnancy, the spouses have a successful subsequent pregnancy. To do this, it is important to strictly follow the instructions of doctors, namely to take a proper break between pregnancies. For full physiological recovery after a spontaneous miscarriage, it takes from several weeks to a month, depending on at what time the pregnancy was terminated. For example, certain pregnancy hormones remain in the blood for one or two months after a spontaneous miscarriage, and in most cases menstruation begins 4-6 weeks after the termination of the pregnancy. But psycho-emotional recovery often takes much longer.

It should be remembered that the observation of a pregnant woman with habitual miscarriage should be carried out weekly, and if necessary, more often, for which hospitalization is carried out in a hospital. After establishing the fact of pregnancy, an ultrasound examination should be performed to confirm the uterine form, and then every two weeks until the period at which the previous pregnancy was terminated. If, according to the ultrasound, the fetal cardiac activity is not recorded, then it is recommended to take fetal tissues for karyotyping.

Once fetal cardiac activity is detected, additional blood tests are unnecessary. However, in later stages of pregnancy, in addition to ultrasound, an assessment of the level of α-fetoprotein is desirable. An increase in its level may indicate malformations of the neural tube, and low values ​​- chromosomal abnormalities. An increase in the concentration of α-fetoprotein for no obvious reason at 16-18 weeks of gestation may indicate the risk of spontaneous abortion in the second and third trimesters.

Assessment of the karyotype of the fetus is of great importance. This study should be carried out not only for all pregnant women over 35, but also for women with recurrent miscarriage, which is associated with an increased likelihood of fetal malformations during subsequent pregnancy.

When treating recurrent miscarriage of an unclear cause, IVF can be considered one of the alternatives. This method allows you to perform a study of germ cells for chromosomal abnormalities even before in vitro fertilization. The combination of the application of this technique with the use of a donor egg yields positive results in the onset of the desired full-fledged pregnancy. According to statistics, full-fledged pregnancy in women with recurrent miscarriage after this procedure occurred in 86% of cases, and the frequency of miscarriages decreases to 11%.

In addition to the described various methods of treating recurrent miscarriage, it should be noted that non-specific, background therapy, the purpose of which is to remove the increased tone of the muscular wall of the uterus. It is the increased tone of the uterus of various natures that is the main cause of premature miscarriages. Treatment involves the use of no-shpa, suppositories with papaverine or belladonna (injected into the rectum), intravenous drip of magnesia.

Prolonged pregnancy- This is a pregnancy in which there is an increase in the gestational age, but there are no violations from the fetus, placenta and amniotic fluid.

Premature pregnancy:

Etiology undermaturity and overmaturity is the same:

Infection (both genital and extragenital).

Complications of pregnancy (preeclampsia, abnormal fetal position, polyhydramnios).

Injuries (including abortion, mental trauma).

Anomalies of the female genital organs (infantilism, age-related fibromatosis, bicornuate uterus, etc.).

Endocrinopathies and other extragenital diseases.

Chromosomal abnormalities.

Social and professional harm.

Classification of preterm labor:

Threatening (characterized by the appearance of pulling or cramping pains inside the abdomen or lower back, an increase in the amount of mucous discharge from the vagina, the tone of the uterus is increased).

Beginning (contractions can be both regular and irregular, but they are effective (lead to the opening of the cervix). If the opening is more than 2 cm - the onset of labor. An objective diagnosis is made on the basis of cardiac monitoring of the contractile activity of the uterus for 30 minutes.

Treatment... Conservation therapy in the Department of Pregnancy Pathology:

Bed rest.

Rest (even a vaginal examination is excluded).

Psychotherapy.

Sedatives, tranquilizers.

Tocolysis (tokos (Greek) - childbirth, lysis - dissolve, relax) - therapeutic measures aimed at relaxing the uterine muscles. There are 5 main tocolytic groups:

- adrenomimetics:

Partusisten;

Salbutamol;

Alupent;

Ritodrin;

Genipral;

Bricanil.

Partusisten is assigned according to the scheme:

First, intravenous 0.5 mg in 10 ml of the drug is dissolved in 400 ml of physical. solution or glucose and injected intravenously 5-20 drops / min for 8-12 hours. 30 minutes before the end of the dropper, 1 tab (0.5 mg) of partusisten is given inside, up to 6 tab per day. In the following days, the dose of the tablet preparation is reduced. Treatment should be long-term (up to 2 months). This drug can be administered up to 37 weeks of gestation. Side effects: tachycardia, hypotension, palpitations, headache, nausea, vomiting, with prolonged use - a tendency to constipation (in this case, Regulax is prescribed). These side effects are more common with overdose and intolerance. Contraindications for the appointment of -mimetics: cervical opening more than 2 cm, intrauterine infection, spotting, congenital malformations and fetal death, cardiovascular pathology, hypotension. To eliminate side effects, group 2 tocolytics (calcium antagonists) are prescribed.

Calcium antagonists:

Isoptin (phenoptin, veropamil);

Nifedipine (corinfar, cordipine).

Dose: 0.04 mg (tab) 2-3r / day for up to 5 days.

Prostaglandin synthetase inhibitors:

Indomethacin (suppositories or tablets). Dose: 200mg / day.

The course is 5 days.

Inhibitors of the release of oxytocin and its binding to receptors:

10% solution of ethanol (dissolve 5-6 ml of 96% ethanol in 500 ml of isotonic solution or glucose) should be administered intravenously drip for 4-12 hours, it can be repeated for 2-3 days. Side effect: alcohol intoxication in the fetus - lethargy, weakness, depression of the respiratory center.

Other tocolytics:

Antispasmodics (no-shpa, papaverine, etc.).

Magnesia sulfate (i / m or i / v 25% solution from 10 to 30 ml).

The course of preterm labor:

Premature rupture of amniotic fluid (i.e. before the onset of labor; early rupture of amniotic fluid - with the onset of labor, but before the cervix opens). the doctor's tactics - prolongation or termination of pregnancy - depends on the presence or absence of infection or the risk of infection, on the presence or absence of congenital malformations of the fetus. If there are no deviations and the gestational age is less than 34 weeks, then the pregnancy can be prolonged.

Abnormalities of labor.

Fetal hypoxia (change in heart rate, green amniotic fluid).

Injuries to the mother and fetus (usually intrapartum).

Bleeding from the uterus, genital tract.

Management of preterm labor(in a special maternity home for undermaturity):

Treatment of hypoxia.

Cardiomonitoring study (to identify abnormalities of labor and fetal pathology).

The peculiarity of anesthesia - promedol is not recommended to be used, it is better - long-term epidural anesthesia.

Glucose-vitamin-hormonal-calcium background (GVGKF).

Prophylaxis in the 1st period of SDR with glucocorticoids, and if they are contraindicated - with aminophylline.

In the 2nd period, the presence of a pediatrician is mandatory, careful, gentle management is necessary. The pediatrician must prepare everything for resuscitation n / a: warm underwear, diapers, heated incubator, in which the initial treatment is performed n / a.

Reducing the resistance of the muscles of the perineum to the head of the child (for this, pudendal anesthesia is done, irrigation of the perineum with lidocaine).

If the weight of the fetus is up to 2 kg, childbirth is carried out without protection of the perineum. If the weight of the fetus is more than 2 kg - perineo- or episiotomy.

Obstetric forceps are not used for premature pregnancies.

Prevention of undermaturity:

Healthy lifestyle, peace.

Preclinical diagnostics (colpocytology, karyopycnotic index, etc.).

Sanatoriums for pregnant women.

Hospitalization at a critical time (individual, for example, the time of the previous miscarriage).

Timely hospitalization.

Postpartum leave.

Postterm pregnancy.

Signs:

Stopping the weight gain of the pregnant woman.

Reduction of abdominal circumference (due to lack of water).

High standing of the fundus of the uterus.

Restriction of fetal mobility.

Signs of fetal hypoxia (changes in fetal heart rate and green amniotic fluid).

Lack of maturity of the cervix, dense bones of the skull, narrow fontanelles (with vaginal examination).

With dopplerometry - a decrease in uteroplacental blood flow.

Ultrasound: a decrease in the thickness of the placenta, calcification, lack of water, a large fetus, rarely - hypotrophy, no increase in biparietal size, thickening of the skull bones.

The body is not ready for childbirth. In addition to the cervical test, the oxytocin and colpocytological test are negative; prolongation of types 3 and 4 of smears is characteristic.

Hormone test:  the content of the level of estrogen in plasma (for a given period).

Tactics:

With prolonged pregnancy - expectant.

With a post-term pregnancy:

postterm pregnancy is a relative indication for a cesarean section.

after preparation of the body for childbirth (HVGKF, endocervical application of prostaglandins (prepedil-gel (PgE2), labor induction is performed (prostaglandins with oxytocin). Ineffectiveness of labor induction is also a relative indication for KS surgery.

Prevention of overdue :

Healthy lifestyle.

Timely hospitalization of a woman in the department of pathology of pregnant women, especially those who have a reason for prolongation.

Undermaturity pregnancy is considered spontaneous termination in the period from 22 to 37 weeks Termination of pregnancy up to 16 weeks is early spontaneous miscarriages, from 16 weeks to 28 weeks - late spontaneous miscarriages, from 28 weeks to 37 weeks - premature birth.

ETIOLOGY

The etiological factors of miscarriage are complex and varied. This creates significant difficulties in diagnosis, choice of treatment methods and prevention of miscarriage. Under the term "habitual miscarriage" many obstetricians-gynecologists understand termination of pregnancy 2 or more times.

The main reasons for termination of pregnancy:

Genetic.

Neuro-endocrine (hyperandrogenism of the adrenal genesis, hyperandrogenism of the ovarian genesis, dysfunction of the thyroid gland, etc.).

Infectious diseases of the female genital organs, general infectious diseases.

Anomalies in the development of female genital organs.

Genital infantilism.

Myoma of the uterus.

Extragenital non-infectious diseases of the uterus.

Complicated pregnancy.

Isthmico-cervical insufficiency.

Genetic diseases. An important role in the etiology of spontaneous miscarriages in early pregnancy is played by chromosomal abnormalities leading to the death of the embryo. So, up to 6 weeks of pregnancy, the frequency of chromosomal abnormalities is 70%, at 6-10 weeks - 45% and up to 20 weeks - 20%. Cytological examination reveals various variants of chromosomal aberrations (trisomy, monosomy, translocation, etc.). Most chromosomal abnormalities are not hereditary and arise in the gametogenesis of the parents or in the early stages of zygote division.

Neuro-endocrine diseases. In the case of hyperplasia of the reticular zone of the adrenal cortex or the formation of a tumor in it, which leads to atrophy of other layers of the adrenal glands, adrenogenital syndrome can be combined with Addison's disease. With hyperplasia of the reticular and fascicular areas of the adrenal cortex, adrenogenital syndrome and Cushing's syndrome develop. Such severe lesions of the adrenal cortex are not typical for premature birth.

The erased forms of Cushing's syndrome can be the cause of miscarriage. Cushing's syndrome develops as a consequence of hyperplasia of the fascicular zone of the adrenal cortex and, like adrenogenital syndrome, can be caused by hyperplasia or a tumor. With adrenal insufficiency (Addison's disease), a high incidence of early and late miscarriages is also noted.

Of all the diseases that are accompanied by ovarian hyperandrogenism, the Stein-Leventhal syndrome, which has several forms, is of greatest importance in the problem of undermaturity. Thanks to the success of therapy, women suffering from this disease can have a pregnancy, which often proceeds with symptoms of threatened termination. At the same time, there is a high frequency of spontaneous miscarriage. At the heart of Stein-Leventhal syndrome is a violation of steroidogenesis in the ovaries.

With pronounced hypofunction of the thyroid gland, as a rule, infertility occurs, and in milder forms, miscarriage. With hyperfunction of the thyroid gland, miscarriage occurs no more often than in the population. Pregnancy is contraindicated in severe hyperthyroidism.

Infectious diseases of the female genital organs, general infectious diseases. One of the common causes of miscarriage is latent infectious diseases, such as chronic tonsillitis, mycoplasma infection, chronic inflammatory diseases of the female genital organs, chlamydia, viral diseases.

Abnormalities in the development of the uterus in recent years, they have been detected a little more often due to the improvement of research methods (hysterosalpingography, ultrasound scanning). Among women suffering from premature pregnancy, uterine malformations were noted in 10.8% -14.3% of cases. Most researchers see the reasons for reproductive dysfunction in the anatomical and physiological inferiority of the uterus, accompanying isthmic-cervical insufficiency and ovarian hypofunction.

Malformations of the female genital organs are often combined with anomalies in the development of the urinary system, since these systems are characterized by a common ontogeny. With miscarriage, the following types of uterine anomalies are most often encountered: intrauterine septum (often incomplete), two-horned, saddle-shaped, one-horned and very rarely double uterus.

The mechanism of termination of pregnancy with some malformations of the uterus is associated not only with ovarian hypofunction, but also with a violation of the process of implantation of the ovum, insufficient development of the endometrium, due to inadequate vascularization of the organ, close spatial relationships, functional features of the myometrium.

Genital infantilism characterize the underdevelopment of the female genital organs and various disorders in the hypothalamus-pituitary-ovary-uterus system. Determination of the level of reception in the endometrium made it possible to confirm the assumption that a woman's body has an inadequate tissue response to ovarian hormones.

Myoma of the uterus - one of the reasons for termination of pregnancy. According to E.M. Vikhlyaeva and L.N. Vasilevskaya (1981), in every 4-5th patient with uterine fibroids, pregnancy was complicated by the threat of termination, and spontaneous miscarriages were observed in 5-6% of patients. Premature termination of pregnancy with uterine fibroids may be due to the high bioelectric activity of the myometrium and increased enzymatic activity of the contractile complex of the uterus. Sometimes the threat of termination of pregnancy is due to malnutrition in the nodes or their necrosis.

Extragenital diseases of the mother are one of the most common causes of abortion (cardiovascular diseases, hypertension, chronic diseases of the lungs, kidneys, liver, etc.).

Complicated pregnancy. Among the factors of termination of pregnancy, its complicated course is of great importance. Toxicosis, especially severe forms, both early and late, lead to termination of pregnancy. This also includes the abnormal position of the fetus, anomalies of attachment of the placenta, detachment of the normally located placenta, multiple pregnancy, polyhydramnios, oligohydramnios.

Isthmic-cervical insufficiency occurs from 20% to 34% of cases and can be traumatic (anatomical) and hormonal. In the first case, cervical insufficiency is caused by trauma to the cervix in the area of ​​the internal pharynx, in the second - hormonal deficiency (insufficient production of progesterone).

EXAMINATION OF WOMEN SUFFERING BY UNEXPECTED PREGNANCY

It is advisable to start the examination of women suffering from premature pregnancy when the patient is out of pregnancy. In this period, they have much more opportunities for diagnosing isthmic-cervical insufficiency, malformations of the genital organs, intrauterine adhesions, genital infantilism, as well as for studying the characteristics of endocrine organs. With such an examination, the background is determined against which a miscarriage or premature birth occurs, and create the prerequisites for the use of appropriate therapy in order to prevent premature pregnancy.

CLINIC

At the Helsinki Convention, Russia signed agreements in which, among others, there were recommendations to consider premature birth from 22 weeks to 37 weeks of pregnancy, when a child is born weighing from 500 g to 2500 g, 35-45-47 cm long, with signs of immaturity, prematurity ...

By clinic it is necessary to distinguish: threatening premature birth, beginning and beginning.

Threatening premature birth is characterized by pain in the lumbar region and lower abdomen. The excitability and tone of the uterus are increased, which can be confirmed by the data of hysperography and tonusometry. At vaginal examination, the cervix is ​​preserved, the external os of the cervix is ​​closed. In multiparous, it may skip the tip of the finger. Increased fetal activity. The presenting part of the fetus is pressed against the entrance to the small pelvis.

At incipient preterm labor- severe cramping pains in the lower abdomen or regular contractions, which is confirmed by hysterography data. With a vaginal examination, the deployment of the lower segment of the uterus, shortening of the cervix, and often its smoothing are noted.

For started premature birth characterized by regular labor and the dynamics of cervical dilatation (more than 3-4 cm), which indicates a far-reaching pathological process and its irreversibility.

The course of preterm labor has a number of features. These include frequent premature rupture of amniotic fluid (40%), abnormalities of labor (weakness, discoordination), rapid or rapid labor with isthmic-cervical insufficiency or protracted, due to an immature cervix, unpreparedness of the systems of neurohumoral and neuroendocrine mechanisms of regulation, fetal hypoxia. Bleeding is possible in the successive and early postpartum periods, due to a violation of the mechanisms of placental abruption and retention of parts of the placenta, infectious complications during childbirth (chorioamnionitis) and the postpartum period (endometritis, phlebitis, etc.).

DIAGNOSTICS

Diagnosis of threatening and incipient preterm labor often presents certain difficulties. When examining a pregnant woman, it is necessary to find out: the cause of the premature birth; determine the duration of pregnancy and the estimated weight of the fetus, its position, presentation, heartbeat, the nature of vaginal discharge (water, bloody discharge), the state of the cervix and fetal bladder, the presence or absence of signs of infection, the stage of development of preterm labor (threatening, incipient, incipient) , because therapy should be strictly differentiated.

For the purpose of a more objective assessment of the obstetric situation in preterm labor, the tocolysis index proposed by K. Baumgarten in 1974 can be used (Table 1). The sum of the points gives an idea of ​​the index of tocolysis: the smaller it is, the more successful the therapy can be. The larger it is, the more likely it is that childbirth has entered an active phase and therapy to maintain pregnancy will be unsuccessful.

Midwifery tactics

Depending on the situation, adhere to conservative expectant(prolongation of pregnancy) or active management tactics for premature pregnancy.

BAUMGARTEN TOKOLYSIS INDEX

Unfortunately, very, very many. These include both various risk factors of a social, medical, physiological nature, and unforeseen life circumstances (for example, an emergency caesarean section). The most important thing - no matter what the reason for the child - is to do everything depending on doctors and parents to nurture him, so that in the future he will be no different from his full-term peers. Premature (as defined by WHO) is a child who was born at the age of 22 to, weighing from 500 grams to 2500 grams.

Let's take a closer look at all sorts of prerequisites for the premature termination of pregnancy:

1.Socio-demographic reasons:

• low living (social) level of the family;
• too early or vice versa - late age for pregnancy (there is a tendency for an increase in the incidence of undermaturity depending on the age of the parents - the younger (less than 17-18 years) and the older (more than 35 years) the expectant mother, as well as the older the father of the child (more 50 years), the higher the likelihood of premature termination of pregnancy);
• problems in family life, frequent scandals, lack of understanding;
• unwanted pregnancy (as a factor in the psychological termination of pregnancy);
• poor nutrition and bad habits of a pregnant woman.

2.Medical reasons:

• pregnancy that occurred earlier than one to three years after the previous birth;
• the woman has chronic diseases (endocrine system, gynecological, genetic), as well as burdened heredity on the part of either parent;
• acute and infectious diseases suffered by a woman during pregnancy;
• severe early toxicosis, aggravated preeclampsia and other pathologies of pregnancy;
• undergone surgical interventions (operations) and physical injuries (especially the abdomen) while carrying a child;
• unstable mental and emotional state of a pregnant woman;
• hemolytic disease of the fetus, which developed against the background of incompatibility with the mother by blood group or by Rh factor;
• previous surgical termination of pregnancy (induced abortion), especially if complications arose during or after the operation;
• multiple pregnancy;
• various defects in the structure and development of the uterus and cervical canal (for example, bicornuate uterus, underdeveloped cervix);
• presentation or premature placental abruption;
• polyhydramnios or premature discharge of amniotic fluid;
• defects in the development of the fetus or its intrauterine death.

3.Environmental and working conditions:

• the aggressive environment in which the expectant mother lives (for example, proximity to the Chernobyl zone or other hazardous radiation facilities, living near a chemical plant, etc.);
• harmful working conditions where any of the child's parents works;
• heavy physical labor in which a pregnant woman is involved (for example, prolonged standing during the working day, work on an assembly line, work involving the transfer of heavy loads).

Causes of premature pregnancy there are many more, and we simply do not have enough time or energy to list them all. In addition to the above reasons, there are also cases where the cause of the premature onset of labor remains unknown. Therefore, at the first suspicion of the threat of the onset of premature labor, immediately consult a doctor who will determine the cause of this phenomenon and take all the necessary measures to continue carrying the child.

Prevention of premature pregnancy

Prevention of this pregnancy pathology should be started even when planning the conception of a baby.

To do this, a woman (and a man also does not hurt) needs:

• be sure to treat all the chronic and acute diseases that she has (for which it is necessary to take responsibility for the passage of the necessary ones when planning a pregnancy!);
• observe the rules of intimate hygiene, as well as conduct a discriminating sex life;
• protect yourself from unwanted pregnancy (according to statistics, more than half of the cases of undermaturity occur in women who had abortions shortly before pregnancy!);
• do not abuse alcoholic beverages, quit smoking;
• eat right, replenish the supply of vitamins in your body;
• avoid stress, anxiety, nervous strain.

When you discover the first signs that you are pregnant, do not postpone a visit to the gynecologist and registration. This is the only way you can avoid medical errors in calculating the true gestational age, which is one of the most common causes of premature pregnancy, especially if you gave birth at the 36th - 37th week.

As you know, at present, the problem of "birth trauma" in medicine is of great importance. Therefore, despite the extensive knowledge in this area, the individual risk of spontaneous delivery in premature pregnancy is often underestimated only because it is rather difficult and unusual to consider this complex process in terms of the category of "trauma".

Thanks to modern methods used in obstetric practice (echography, computed tomography), it was shown that even in the antenatal period, before the onset of labor, cerebral hemorrhages are possible. At the same time, it was possible to obtain scientific evidence of the origin of intracranial hemorrhages as a result of the direct impact of labor pains on the fetal skull during the labor act. So, the effect of intrauterine pressure on the fetal head in the II stage of labor can reach 15 kg.

Some foreign authors believe that, pathophysiologically and neurosurgically, childbirth does not take place without latent craniocerebral trauma, that is, without repeated changes under pressure in the cerebral and facial skull, the base of the skull and the cranio-cervical junction in the axial organ of the spinal column with accompanying disorders of the macro - and microcirculation. The embryonic brain from the moment of its appearance has fully developed "differentiated neurons and in no case is it a shapeless homogeneous mass. Therefore, irreversible circulatory disorders can form in the entire cranial region with extensive subdural and intraventricular hematomas and intraocular hemorrhages.

At the same time, the onset of microcirculatory acidosis turns into a life-threatening cerebral edema. A huge load during childbirth on the fetus can manifest itself in the form of a disease only many years later.

Depending on the length of service and experience of the doctor, the frequency of performing cesarean sections during full-term pregnancies fluctuates significantly. When considering the expansion of indications for a caesarean section in premature pregnancy, it is important to take into account the mortality of women in labor and parturient women in preterm birth, which, according to research data, amounted to 26.8% of the total number of pregnant women, women in labor and parturient women who died in the country. The leading causes of death were late toxicosis (26.8%), extragenital diseases (23.4%), bleeding (21.9%), sepsis (12.4%).

41.4% of women with late toxicosis were delivered by caesarean section; with extragenital pathology, 13.4% were delivered by caesarean section. It should be noted that the overwhelming majority of women (61.8%) were delivered by caesarean section. At the same time, an analysis of deaths in preterm birth showed that 93.4% of women died after childbirth. Thus, caesarean section for premature pregnancy, as well as for term delivery, remains a high-risk intervention in terms of maternal mortality and morbidity.

The results of a scientific analysis of perinatal mortality show that the main causes of it are fetoplacental insufficiency with a number of complications of pregnancy and extragenital diseases (especially diabetes mellitus), birth trauma and a combination of birth trauma with respiratory failure and pulmonary atelectasis, as well as fetal malformations. Knowledge of these main causes of perinatal mortality allows us to outline reasonable ways to reduce them both in the ante- and intra-natal and postnatal periods. In particular, attempts are being made to study the effect of the active phase of labor and the mode of delivery on the incidence of intracranial hemorrhage. A number of studies have shown that the overall incidence of hemorrhages that developed in the first 7 days of life was approximately the same as those that were delivered by caesarean section in the early and late stages of labor, but the time of their occurrence was different. In the majority of children extracted by cesarean section before the active phase of labor, hemorrhages developed within 1 hour of life. In children delivered during the active phase of labor, hemorrhage progression to grade III-IV was noted, regardless of the mode of delivery.

Earlier works discussed the issue of performing a cesarean section in breech presentation in premature birth and in the presence of twins with fetuses weighing less than 2500 g, if one of them is in breech presentation. So, for example, if the operation of a cesarean section with a breech presentation of the fetus and a gestational age of 32-36 weeks was carried out with a fetal weight of 1501-2500 g, then the number of newborns who died after the operation was 16 times less than in preterm birth through the natural birth canal. It is important to note that the condition of newborns delivered by caesarean section was significantly better.

At the same time, severe and moderate asphyxia was 2.5 times less in the group of children delivered by caesarean section. Therefore, it is recommended to use this operation more widely in preterm labor. Other authors, despite an increase in the frequency of caesarean section in breech presentation and preterm birth, did not find any differences in the condition of children weighing from 1501 to 2500 g compared with children born through the vaginal birth canal. Therefore, a number of obstetricians believe that a decrease in perinatal mortality should be due to the prevention of premature birth, continuous monitoring of the fetus.

According to modern data, the incidence of caesarean section in premature pregnancies is about 12%. Moreover, in almost half of the cases, it is carried out in a planned manner, in every fifth woman - in connection with bleeding and breech presentation of the fetus or its malnutrition. In half of women, the operation is carried out during the labor act. Most authors now tend to consider very low body weight (less than 1500 g) for caesarean section as worthy of further study. Noteworthy are the outcomes of caesarean section before 32 weeks of gestation. At the same time, the main indications for surgery are: acute disturbance of the fetus, chronic hypoxia, premature birth by itself, multiple pregnancy and inevitable premature birth, mother's diseases, combined indications. About 70 % children delivered before 32 weeks of gestation had normal psychomotor development when followed up to 5 years. The advantages of operative abdominal delivery in case of prematurity in the presence of a breech presentation of the fetus are convincingly shown. Some authors believe that the incision in the uterus affects the outcome of the operation for the newborn, since an extremely gentle delivery is necessary at a gestation period of 26-32 weeks and a fetal weight from 501 to 1500 g. At the same time, during these periods, poor deployment of the lower segment of the uterus is observed, and the head circumference at 28 weeks is 25 cm and about 30 cm at 32 weeks of gestation, the length of the fetus, respectively, is 23 cm at 26 weeks and 28 cm at 32 weeks of gestation.

At the same time, some authors believe that premature infants extracted by caesarean section have a number of features during the neonatal period. The outcome of the operation for the fetus is determined by complications of pregnancy, the presence and condition of a scar on the uterus, extragenital diseases of the mother, as well as the degree of maturity of the fetus. It is believed that in modern conditions, a cesarean section in premature pregnancy, and especially in the presence of a scar on the uterus, should be carried out only on strict indications from the mother.

Despite the fact that many authors refrain from caesarean section in breech presentation and fetal weight less than 1500 g, it should be noted that the incidence of postnatal death of children is 2 times less during caesarean section, and the frequency of low scores on the Apgar and intracranial hemorrhage did not differ in both groups. The highest frequency of surgery was at a gestational age of 29-34 weeks. At the same time, it was noted that doctors do not have the opportunity to learn how to give birth with a breech presentation of the fetus, since for each student a year there are two births with a breech presentation of the fetus. Therefore, the frequency of cesarean section in breech presentation may increase in the future and reach 100%. Currently, with breech presentation, all births must end with a caesarean section. However, there was no significant relationship between perinatal mortality rates and the incidence of caesarean section. Therefore, to this day, there is an acute problem - whether a cesarean section reduces the risk of delivery in premature birth with a fetus in breech presentation.

Thus, the use of a caesarean section does not reduce the incidence of hypoxia, birth trauma, encephalopathy, or neonatal mortality. Therefore, it is concluded that in premature birth with a fetus in breech presentation, the use of caesarean section at 29-36 weeks does not have any advantages over vaginal delivery. Operation up to 29 weeks in most cases can be justified. It has also been found that fetal malformations and fetal respiratory distress are more common in breech presentation of the fetus.

The issue of morbidity and mortality among premature babies born in breech presentation with a birth weight of 1500 g or less, depending on the method of delivery (vaginal or abdominal delivery), deserves much attention. Few studies based on a small number of observations conclude that the effect of the method of delivery on infant mortality has not been identified. The causes of infant mortality in both groups were intracranial hemorrhage and extreme immaturity. Objective research methods (pH value in the blood of the umbilical cord, assessment by the Apgar scale, etc.) show that newborns retrieved by surgery had better adaptive parameters compared with children delivered by vaginal delivery. These studies indicate the beneficial effect of timely and sparing delivery by cesarean section on the incidence of low birth weight babies born in breech presentation. In particular, caesarean section surgery can reduce perinatal mortality in breech presentation and low birth weight infants by 50%. In addition, babies extracted by caesarean section had a lower incidence compared to babies born through a vaginal delivery. Therefore, conclusions are drawn even about the expansion of indications for abdominal delivery in children with low birth weight.

Much attention should be paid to issues related to the management of pregnancy and childbirth in multiple pregnancies. A number of modern works question whether an increase in the frequency of caesarean section would improve the living conditions of children at birth. It should be emphasized that after 35 weeks of gestation, the neonatal outcome for the second fetus does not depend on the mode of delivery. Other authors believe that if the second fetus is not in the cephalic presentation, then it is necessary to perform a caesarean section, even if the first fetus was born through the vaginal birth canal. A number of researchers believe that with a weight of children over 1500 g, birth through the vaginal birth canal is also safe, as with a caesarean section. At the same time, some authors believe that the extraction of the fetus at the pelvic end of the second fetus weighing more than 1500 g is the most expedient alternative to the caesarean section and external rotation. Therefore, the optimal choice of the method of delivery of the second twin fetus remains a controversial issue of modern obstetrics. External rotation of the second breech fetus from twins is a relatively new advance in the management of multiple pregnancies. However, a number of studies have shown that external rotation is associated with more failure than extraction of the fetus at the pelvic end. At the same time, no differences were found in neonatal mortality with these methods of delivery. Thus, the extraction of the fetus by the pelvic end of the second fetus from twins weighing more than 1500 g is an alternative to caesarean section or external rotation. However, so far there is little comparative research on this issue. This is probably due to the insufficient number of studies on fetal development in twin pregnancies. The development of the fetus during twin pregnancy is influenced by such parameters as the state of the chorion and the presence of interfetal anastomoses in the placenta in the case of monozygous twins. It is noted that with a twin pregnancy at 32-34 weeks, fetal growth slows down. Thus, the body weight of newborn twins is 10% less than the weight of the fetus in a singleton pregnancy. The slowdown in growth can affect both twins and one of them, and this difference can be 25%. The slowdown in fetal development affects primarily the length and weight of the infant's body. When studying the status of newborns extracted by cesarean section, it is necessary to take into account the effect of anesthesia and the duration of the interval: uterine incision - delivery on the condition of the newborn. Moreover, if the duration of this interval was less than 90 s, acidosis was more pronounced under conditions of epidural analgesia. With lengthening of this interval under general anesthesia, an increase in acidosis was also noted. To reduce the trauma of newborns, especially those with a low weight, at present, in the technique of cesarean section, great importance is attached to the vertical incision of the uterus in the region of its lower segment, especially in the transverse position, placenta previa, during hysterectomy and the presence of uterine fibroids in its lower segment. This issue remains especially relevant when removing a fetus weighing 1000-1500 g (isthmic-corporal with a longitudinal section of the uterus).

It is essential to recognize that the increase in the frequency of caesarean section in premature pregnancy is increasingly based on neonatological indicators - immaturity, perinatal infection, the risk of birth trauma for the mother, fetus and newborn. Therefore, there are voices in defense of the position that caesarean section should not be performed before 32 weeks of pregnancy.

In the prognostic assessment of premature fetuses and fetuses with hypotrophy (a sharp delay in fetal growth): with a delay in fetal growth, the survival rate of children with a caesarean section is currently almost 40%, and with prematurity - 75%. The main causes of death were placenta previa (30%), fetal malformations, polyhydramnios, Rh-conflict. In general, the risk of mortality for fetuses weighing less than 1500 g is significantly higher with vaginal delivery than with caesarean section. The prognosis for a fetus with a gestational age of less than 28 weeks is usually doubtful, with a gestational age of 28-32 weeks, it is more favorable. It is important to emphasize that the risk of developing respiratory distress syndrome in newborns is proportional to the gestational age and, possibly, is higher in newborns delivered by caesarean section than during vaginal delivery.

In the literature, there are indications of an increased risk of developing respiratory distress syndrome depending on the indications for a caesarean section, including prenatal bleeding, diabetes mellitus, abnormal cardiotocogram in the fetus, toxicosis of pregnant women. Respiratory distress syndrome increases as the weight of the infant decreases: at 1000-1499 g - 25%; 1500-1999 g - 14%; 2000-2499 - 7.1%.

Thus, the need for operative delivery in premature pregnancy occurs in almost 75% of cases before the onset of labor.

The main indications for a cesarean section on the part of the fetus are:

• fetal hypoxia, mainly due to placental insufficiency due to late toxicosis, especially in combination with diabetes mellitus;
• breech presentation of the fetus when symptoms of disability appear.

Almost 50% of caesarean section operations in premature pregnancy are performed at the onset of labor. The most common indications for it are:

• transverse and oblique position of the fetus;
• deterioration of the fetus against the background of extragenital pathology (mainly diabetes mellitus) in women in labor;
• threatening rupture of the uterus along the scar;
• ineffectiveness of labor induction with the outflow of amniotic fluid.

In conclusion, it should be noted that perinatal mortality during cesarean section in women with premature pregnancy is only 1.3 times higher than perinatal mortality during vaginal delivery birth canal).

The highest perinatal losses are observed among newborns weighing 1500 g or less both during operative delivery and during vaginal delivery, and the perinatal mortality rates in both cases are practically the same and exceed 75% in all years of observation. This means that in the absence of a well-developed highly qualified neonatological service, a child's weight of 1500 g or less is a relative contraindication to abdominal delivery in the interests of the fetus; a cesarean section in such conditions should be performed mainly for health reasons on the part of the mother.

Thus, women with preterm birth should be classified as high risk. They have a relatively frequent history of miscarriage, artificial termination of pregnancy, anomalies in the development of the genital organs, and extragenital diseases. Therefore, in the group of women with various obstetric complications, the incidence of preterm birth is higher. Childbirth should be carried out in a specialized obstetric hospital, where there are opportunities to prevent possible complications from the mother and the fetus.