Miscarriage (abortion)

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Miscarriage (abortion)

  1. 1. 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 www.doctor.sd
  2. 2.  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) www.doctor.sd
  3. 3.  --poorly controlled diabetes.  --thyroid diseases.  --SLE.  --von willebrand disease.  --wilson disease www.doctor.sd
  4. 4.  3)uterine abnormality;-  --fusion defects (bicornate or septate uterus)  --incompetent cervical os.  --sub mucous fibroid.  --asherman syndrome www.doctor.sd
  5. 5.  Infections;-  --pyrexial infections (malaria)  --other micro-organisms.  Syphilis, rubella, variola, herpes simplex, toxoplasmosis, cytomegalovirus, brucella, mycoplasma& others www.doctor.sd
  6. 6.  Poisons;-  Cytotoxic drugs, high levels of lead, quinine, aniline, smoking & alcohol.  Immunological factors;-  --lupus anticoagulant & anticardiolipin antibodies.  --rhesus incompatibility.  Trauma;-(amniocentesis, pelvic surgery) www.doctor.sd
  7. 7.  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 www.doctor.sd
  8. 8.  ---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. www.doctor.sd
  9. 9.  --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. www.doctor.sd
  10. 10.  --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 www.doctor.sd
  11. 11.  -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. www.doctor.sd
  12. 12.  -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. www.doctor.sd
  13. 13.  --three or more consecutive miscarriage.  -occur in 1% of cases. www.doctor.sd
  14. 14.  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 www.doctor.sd
  15. 15.  --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 www.doctor.sd
  16. 16.  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. www.doctor.sd
  17. 17.  --E-coli.  --streptococci (hemolytic, non hemolytic, & anaerobic) .  --staphylococcus auras.  --bacteroids.  --klebsiella.  --proteus.  --pseudomonas. www.doctor.sd
  18. 18.  --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  . www.doctor.sd
  19. 19.  ---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. www.doctor.sd
  20. 20.  --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  www.doctor.sd
  21. 21.  --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 www.doctor.sd
  22. 22.  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 www.doctor.sd
  23. 23.  --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 www.doctor.sd
  24. 24.  --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 www.doctor.sd
  25. 25.  --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;-- www.doctor.sd
  26. 26.  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. www.doctor.sd
  27. 27.  --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. www.doctor.sd

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