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

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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)

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--poorly controlled diabetes. --thyroid diseases. --SLE. --von willebrand disease. --wilson disease

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3)uterine abnormality;- --fusion defects

(bicornate or septate uterus) --incompetent cervical os. --sub mucous fibroid. --asherman syndrome

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Infections;- --pyrexial infections (malaria) --other micro-organisms.Syphilis, rubella, variola, herpes

simplex, toxoplasmosis, cytomegalovirus, brucella, mycoplasma& others

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Poisons;-Cytotoxic drugs, high levels of lead,

quinine, aniline, smoking & alcohol. Immunological factors;- --lupus anticoagulant &

anticardiolipin antibodies. --rhesus incompatibility.Trauma;-(amniocentesis, pelvic

surgery)

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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

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---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.

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--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.

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--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

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-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.

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-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.

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--three or more consecutive miscarriage.

-occur in 1% of cases.

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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

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--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

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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.

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--E-coli. --streptococci (hemolytic, non hemolytic,

& anaerobic) . --staphylococcus auras. --bacteroids. --klebsiella. --proteus. --pseudomonas.

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--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

.

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---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.

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--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

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--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

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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

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--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

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--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

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--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;--

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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.

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--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.

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