MISCARRIAGE (ABORTION)

DR : SARA SIDDIG
definition;-
The expulsion or extraction of a fetus weighing less than
500gm. Or the termination of a fetus before 24
weeks of gestation with no evidence of life.
Incidence;-
15% of clinically apparent pregnancies
Aetiology
1) fetal abnormality;-
-a-chromosomal (the commonest cause)
-(trisomy, monosomy, triploidy &tetraploidy)
-b-structural abnormality (neural tube defect)
-c-genetic.
2)endocrine abnormality;-
--luteal phase inadequacy.
--high LH (pco)
--poorly controlled diabetes.
--thyroid diseases.
--SLE.
--von willebrand disease.
--wilson disease
3)uterine abnormality;-
--fusion defects
(bicornate or septate uterus)
--incompetent cervical os.
--sub mucous fibroid.
--asherman syndrome
Infections;-
--pyrexial infections (malaria)
--other micro-organisms.
Syphilis, rubella, variola, herpes simplex, 
toxoplasmosis, cytomegalovirus, brucella,
mycoplasma& others
Poisons
Cytotoxic drugs, high levels of lead, quinine, aniline,
smoking & alcohol.
Immunological factors
--lupus anticoagulant & anticardiolipin antibodies.
--rhesus incompatibility.
Trauma;-(amniocentesis, pelvic surgery)
Clinical types of miscarriage
 Threatened miscarriage;-
--symptoms and signs of pregnancy
--slight vaginal bleeding.
--pain is absent or mild.
--uterus equal gestation age.
--cervical os closed with minimal bleeding.
--ultrasound shows viable fetus.
--there is no specific treatment, bed rest is advised
.in 50% of cases pregnancy will continue
Inevitable miscarriage
---indicates the pregnancy is doomed to end shortly
---vaginal bleeding usually profuse.
---severe cramping lower abdominal pain.
---dilated internal cervical os.
---any attempt to maintain pregnancy is useless
--resuscitation + ergometrine & then evacuation
&curettage if the pregnancy is less than 12
weeks & uterine stimulation with oxytocin if the
pregnancy is more than 12 weeks.
Incomplete miscarriage
--retention of parts of concepts inside the uterus
--patient usually passes part of the product.
--bleeding usually continue.
--uterine size is less than the period of pregnancy.
--cervical os is opened & products may be felt.
--ultrasound shows retained products.
--treatment is resuscitation & evacuation& curettage.
Complete miscarriage
--all products has been expelled.
--bleeding diminishes & pain ceases.
--uterus size is normal or slightly enlarged.
--cervical os is closed.
--ultrasound shows empty uterine cavity
Missed abortion
-retention of dead fetus inside the uterus.
-may be preceded by symptoms &signs of
threatening miscarriage.
-the symptoms & signs of pregnancy regress.
-sometimes the patient present with brownish
vaginal discharge.
-the uterus ceases to grow & may diminishes in
size.
-cervical os is closed.
-HCG level fall.
-ultrasound shows dead fetus or collapse gestational
sac.
-hazard is from infection, DIC, & psychological
distress of the mother.
-treatment in first trimester is suction evacuation
-in the second trimester is induction by oxytocin after
treatment with mifeprisone or prostaglandinE2
Recurrent miscarriage
--three or more consecutive miscarriage.
-occur in 1% of cases.
Septic abortion
 Definition;-
--any abortion associated with clinical evidence of
infection of the uterus & it contents.
❑ Pathology;-

--any type of abortion can be complicated by

infection. However the majority are associated with
incomplete abortion
 --septic abortion can complicates spontaneous
abortion, but in the majority of cases the infection
occur following illegal induced abortion because;--
1)usually there is no proper aseptic technique & the
instruments used to induce abortion is often unclean
& may carry pathologic organisms directly in the
uterus, the blood stream, or even the
Peritoneal cavity if the uterus is perforated.
2)usually there is incomplete evacuation where the
dead tissues in the uterus form an ideal culture
media for the flora normally found in the lower
genital tract.
3)there may be injury to the genital organs &
adjacent structures particularly the bowels.
The commonest infecting organism are

--E-coli.
--streptococci (hemolytic, non hemolytic, &
anaerobic) .
--staphylococcus auras.
--bacteroids.
--klebsiella.
--proteus.
--pseudomonas.
--rare organisms include, clostridia welchi, cl.
tetani, & cl. Perferingens.
--in the majority of cases (80%) the organism is
of endogenous origin & the infection is usually
confined to the uterine cavity.
--in 15% the infection spread to the tubes,
ovaries, & pelvic peritoneum.
--in about 5% there is generalized peritonitis &
other complications like end toxic shock
---pyrexia & tachycardia are early signs of infection.
---rigors suggest bacteraemia.
---a sub normal temperature is a serious sign & is most
common seen with gas forming organisms.
--the patient may be seriously ill with malaise,
sweating, headache, joint pain.
--abdominal pain either localized or
generalized.
--jaundice is a serious sign indicating hemolysis
due to chemical or hemolytic infection.
--hypotension may be due hypo- volumaemia .
Or endo toxin or both.
--offensive vaginal discharges is present in most
cases &signify local infection & dead tissues
Pelvic examination
--usually reveals a tender uterus, offensive vaginal discharges, dilated
cervix, & intrauterine debris.
--crepitus indicate severe gas forming infection.
--evidence of trauma can be seen.
--a pelvic abscess is indicated by bogginess or fullness &tenderness in
the pouch of Douglas. In such cases diarrhea is a common symptoms
--generalized peritonitis is suspected if there is abdominal distension,
vomiting, or absent bowel sound.
--oligouria may be due to hypovolaemia, end toxin, or drug toxicity.
Haematuria result from glomerular damage and port wine urine is
classic feature of severe clostridial infection
complications
A) immediate;-
1- hemorrhage due to abortion process & due to genital
injuries inflicted during the interference.
2-peritonitis.
3-endotoxic shock.
4-renal failure.
5-DIC.
6-thrombophlebitis.
B) remote;-
1-chronic pelvic infection.
2-infertility due to tubal blockage
investigations
--Hb, Hct, blood grouping & cross matching, &coagulation
profile.
--WBC total & differential usually there is gross
leucocytosis . A low WBCC may be an early
manifestation of septic shock.
--vaginal, cervical, blood & urine culture for aerobic &
anaerobic bacteria.
--serum electrolytes.
--ultrasound scan for retained products.
--x-ray abdomen. Gas under the diaphragm suggest
uterine perforation
treatment
--establish a peripheral intravenous line for
therapy.
--in the presence of shock a central venous
pressure line is helpful (cvp).
--antibiotic therapy appropriate to the common
organisms & known local sensitivities is
commenced immediately.
--in mild cases, ampicillin or cephalosporin oral
metronidazole & or tetracycline
--in more severe cases. Intravenous therapy with
gentamicin or cephalosporin or chloramphenical is
preferable.
--the antibiotics may be change if necessary when the
organisms & their sensitivity have been determined.
--in areas where tetanus is common anti tetanus serum &
tetanus toxoid may be administered.
--blood transfusion is important to correct anemia & to aid
in combat of the infection.
--surgical exploration of the uterus & evacuation of the
retained products is required as soon as possible, but
should be deferred until;--
1-acute resuscitative measures have been
achieved.
2-antibiotic therapy has been established.
--in the absence of excessive bleeding or
deterioration in spite of the above
therapeutic measures an interval of 6 hrs from
commencing therapy is reasonable.
--pelvic abscess require drainage by posterior
colpotomy.
--if trauma is identified laparotomy is usually required
& and the choice between repair of the uterine
damage & hysterectomy is often difficult, but will
be influenced by the degree of trauma & the
nature & severity of infection .
--careful examination of the bowel & urinary tract is
essential.