Habitual Miscarriage

HABITUAL MISCARRIAGE, repeated, without visible causes, spontaneous interruption of pregnancy and usually at the same time of its duration (but sometimes with each new pregnancy the interruption occurs at later stages). H. m. is a fairly common phenomenon, for example, according to Weber's data, H. m. constitutes 7.1% of all cases of spontaneous abortion. In former times, this repeated early death of the fetus and its spontaneous expulsion from the uterus were most often causally connected with syphilis. However, recent clinical observations and serological studies (Wassermann reaction and others) have shown that syphilis plays a comparatively very insignificant role in the etiology of spontaneous abortion in general, and in the origin of H. m. it is responsible for approximately only one fifth of all such cases (Seitz). A purely empirical connection is also established between H. m. and gonorrhea. Although gonorrheal endometritis is a frequent cause of infertility, nevertheless, since along with affected areas of the endometrium there can be completely healthy ones (Bumm), implantation of the fertilized egg is still possible here; however, with further growth of the egg, this healthy tissue proves insufficient to ensure its proper nutrition and sooner or later miscarriage occurs; consequently, in the presence of chronic gonorrhea of the uterine body, habitual miscarriage is possible. H. m. can also be the result of other chronic inflammatory processes, as well as purely hyperplastic processes in the decidual tissue. Besides diseases of the endometrium itself, various uterine diseases can play a role in the origin of H. m., namely: various deviations from the normal position (prolapse, beginning prolapse, sharply expressed flexures and especially retroflexion); deep ruptures of the cervix, as well as an artificially shortened cervix (since this partially exposes the lower pole of the ovum and facilitates the possibility of infection penetrating the uterus); then submucous uterine fibroids, often forming large uterine polyps (according to Nauss, they lead to H. m. in 12%). Various inflammatory processes in the uterus itself and in the peritoneum covering it, as well as in neighboring organs and in the peritoneum lining the walls of the pelvis (chronic metro-endometritis, perimetritis, salpingo-oophoritis, periooophoritis and general pelveoperitonitis, usually simultaneously with parametritis) have very important etiological significance; as a result of all these processes, adhesive inflammation often occurs with the formation of adhesions, bands and bridges, sometimes in the form of dense, unyielding strands and scars, which can distort the normal topographical relationships between the pelvic organs; in any case, they limit the mobility of the uterus and purely mechanically hinder its free growth during pregnancy. If all these inflammatory processes take on such a chronic character, and the inflammation has not yet gone so far as to prevent fertilization, conditions are created in which H. m. can become an inevitable phenomenon. Another local etiological factor of H. m. should be kept in mind, namely uterine fibroids located in the pelvis (especially those "sitting on a broad base" subserous) and various inflammatory, as well as neoplastic processes in the ovaries (ovarian cysts), taking into account not so much the purely mechanical factor, i.e., the size of the tumor, but the circumstance that it can inhibit the formation of the corpus luteum, which plays an important role in maintaining pregnancy (see below). Besides all the local causes mentioned, general constitutional disorders and anomalies, especially infantilism, can of course play a role in the origin of H. m. An infantile uterus can be a cause of H. m. because 1) its mucous membrane is underdeveloped, as a result of which the ovum cannot firmly establish itself in it, 2) its walls are comparatively poor in smooth muscle *b fibers, little capable of stretching and of the physiological hypertrophy and hyperplasia characteristic of pregnancy. One of the most probable explanations for cases of H. m. is disorders of the internal secretion of the ovaries and other endocrine glands (e.g., thyroid gland); particular importance apparently belongs to the hypofunction of the corpus luteum, the hormones of which, as shown by both experiment and clinic, ensure (in the first half of pregnancy) the firm attachment of the dense egg to the uterine wall (experimental destruction of the corpus luteum leads to abortion; treatment with preparations of the corpus luteum can often contribute to maintaining pregnancy in threatened abortion and particularly in H. m.). It is very possible that other general disorders and severe chronic diseases associated with a sharp disturbance of metabolism also have etiological significance, since pregnancy always places increased demands on all systems of the body and on individual organs. Here one should keep in mind: a) decompensated heart defects (in this case, insufficient oxidation of blood and hemorrhages into the placenta and fetal membranes can play a role), b) chronic nephritis (increase in blood pressure, rupture of vessels, white infarcts in the placenta, premature separation of it), c) diabetes, d) tuberculosis and others; however, it must be admitted that such general causes (although they undoubtedly have no less etiological significance than any local changes in the sexual apparatus themselves) in their pathogenetic essence often remain hidden from us, not always fully clear in individual cases despite the most careful analysis of all possible factors. Apparently, the significance of primary insufficient viability of the fetus due to the biological inferiority of the parental sex cells after various acute and chronic infectious diseases (typhoid, malaria, etc.), as well as as a result of various general diseases and generally factors exhausting the entire organism (starvation, narcotics, alcohol, industrial poisons, perhaps even severe experiences traumatizing the entire nervous system and psyche) is also known. Besides all these local and general endogenous causes, purely exogenous factors often play a role in the etiology of H. m., namely various chronic intoxications and first of all by industrial poisons. Cases of chronic lead poisoning in women directly in contact with this poison (as for example in typesetters) are best studied and reflected in the literature. Along with various other disorders (menstrual anomalies, etc.) in them, spontaneous abortions are observed much more frequently than in other workers, and often of the H. m. type. On examination of the fetuses in these cases, changes are found that can easily develop under the influence of lead (cirrhosis of the liver, endarteritis, degeneration of renal epithelium); this assumption has been repeatedly confirmed by chemical analysis, by which lead was found in various organs of the fetus. It is clear that in chronic lead poisoning, all conditions are always present for spontaneous abortion in such women to become a repeated phenomenon, i.e., habitual miscarriage, at least until this chronic intoxication ceases. In the very latest time, Daneff (Daneff, 1931), who specially studied the question of H. m., came to the conclusion that in it an increase in blood pressure in the veins, both peripheral and uterine, is often observed, and on microscopic examination of scrapings from the uterus, the extraordinary enlargement of vessels not only at the site of nidation of the egg but throughout the entire endometrium is striking; it is precisely the veins and lymphatic vessels that turn out to be especially dilated (in some places true ectasias of them are encountered). On ordinary examination of the heart in these cases, nothing particular can be found, except for some impurity of the first aortic tone; however, the electrocardiogram and X-ray usually indicate hypertrophy of the left ventricle. Of great interest is also the report by Vignes, who in one case of H. m. [four consecutive spontaneous abortions, of which the last two were caused by the presence of an acute infectious lesion of the decidual membrane (by streptococci)], by using autovaccine as anti-streptococcal treatment, achieved in the fifth pregnancy a smooth course of it to the very end and as a result finally obtained a living, full-term fetus.

"- Prevention and therapy of H. M. In view of the extreme diversity of etiological factors playing a role in the origin of H. M., and the still far from sufficient clarity in the interpretation of these factors, it is difficult to give any general scheme of prevention and therapy applicable to all individual cases. In particular, the following preventive and therapeutic measures may be useful: general improvement of the health of both parents, improvement of their entire labor (professional) and domestic living conditions, active struggle against all sorts of harmful influences affecting the entire organism, i.e., first of all, elimination of dangers associated with various intoxications and infections, then with general disorders and diseases, with harmful effects of constant physical and mental trauma; general strengthening regimen, use of health-improving natural means-climatic, resort, sanatorium treatment, physiotherapy, physical culture, etc. Specific treatment of syphilis and gonorrhea may have special significance (in cases where the etiological importance of either is not in doubt); a certain significance also has abstinence from a new pregnancy for a certain period, and when it occurs-implementation from the very beginning of a series of preventive measures, among which the appropriate lifestyle of the pregnant woman should be placed in one of the first places. Then the use of various extracts from the ovaries (mainly from the corpus luteum), as well as from other endocrine glands, especially the thyroid gland (Lehrmann recommended iodothyronine in such cases), may prove very useful. The use of iodine in one form or another is recommended by many other authors and, as clinical observations show, it provides substantial benefit in far from isolated cases. Frenkkel (L. Fraenkel) recommends treatment with iodine, lime, and vitamins for H. M., and Danef-foxglove, calcium, Hydrastis, and a vegetable diet. Seitz especially advises paying attention to nutrition, attaches great importance to vitamins and recommends introducing them in large quantities, also using artificial preparations (vigantol). For epizootic abortion in animals-see Infectious abortion."