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Abortion
Abortion
(Miscarriage)
Definition:-
Termination of pregnancy
before 24 weeks of
gestation.
*Occur in 10 – 20% of
confirm pregnancy
Causes
(1) Chromosomal abnormality
-( maternal age > 35 years old)
-> 50% of Miscarriage in first trimester.
e.g.: Trisomy (Down's Syndrome)
Monsomy X (Turner's Syndrom
Triploids and tetraploides
(2) Immunological causes
Anti phospho lipid syndrome.
Anti cardio lipin anti bodies.
(3) Infections
CMV, Toxoplasmosis, syphilis and
other febrile illness like Malaria.
(4) Maternal diseases
DM, HTN , Chronic renal diseases thyroid
diseases.
(5) Congenital of acquired abnormalities
of female internal organ.
(Double uterus, Septate uterus, cervical incompetence,
uterine fibroid)
(6) Drugs
Cytotoxic drugs, caffeine, al cohol, tobacco and cocaine.
(7) Over distension of the uterus
eg: Multiple gestation.
(8) Psychological disorders.
(9)Hormonedeficiency.progesterone,leu
tinizing hormone
MISCARRIAGE
Abortion
Spontaneous Induced
Threatened Recurrent
inevitable
incomplete
complete
Missed
Cont. preg
illlegall
SEPTIC
Legal
Therapeutic
Types
(1) Threatened
miscarriage
Definition:-
painless vaginal bleeding accruing any time between
implantation and 24 weeks gestation.
* Cervix is closed
Clinical Picture:-
Signs and Symptoms of early pregnancy
Mild vaginal bleeding.
Pain slight or absent.
Cervix is closed.
Pregnancy test is + ve
U/S show a living fetus.
Management:-
-Investigation:-
HB% and urine general. Blood grouping and RH
factor.
U/S for fetus.
-Bed rest.
-Treat the cause if present.
-Anti D if mother Rh – ve
Prognosis:-
- in 50% bleeding will stop and pregnancy will continue
(2) Inevitable Miscarriage
Clinical Picture:-
-Vaginal bleeding is excessive with clots.
-Supra pubic colicky pain radiated to the back.
-Cervix is opened. Products of concepts may be
felt in the cervical canal
Management:-
-Resuscitation (I/V Fluid, Blood transfusion and
analgesia ) Ergometrine or Syntocinon.
1->12 weeks medical prostaglandins ,oxytocin
2-<12-surgical Evacuation of the uterus.
-Anti D gamma globulin if mother RH – ve . -
(3) In complete miscarriage
Retention of a part of the product of conception inside the
uterus.
Clinical Picture:-
-Excessive bleeding.
-Abdominal pain.
-Dilated cervix.
-Product of conception in uterus, cervix or vagina.
-The patient may be pale or shocked.
-u/s show some material still remaining in the uterus.
Management:- as the same as inevitable
(4) Complete Miscarriage
All the product of conception has been expelled from the
uterus.
Clinical Picture:-
-Pain and bleeding are usually stop.
-Cervix is close.
-U/S show an empty uterus. -
Management:-
-No further treatment.
-Anti D if mother RH – ve.
-Anti biotic if needed.
-observe the patient for 2 – 3 hours.
(5) Missed miscarriage
Is retention of dead fetus for 4 wks or more before
24weeks of gestation and failure of the uterus to expel
it.
Clinical Picture:-
-History of normal pregnancy.
-Painless recurrent Vaginal bleeding of dark brown blood.
- loss of normal pregnancy symptoms.
-Uterus doesn't increase in size or decrease.
-No fetal movement and No FHS.
Investigation:-
-HCG levels drop in7-10 days and become ->ve
-U/S show fetal death
Treatment:-
-Evacuation of the uterus either:
Medically (Misoprostol 600 – 800 mg/vagina )
surgically: suction curettage.
-Anti D if needed.
-Anti biotic.
Complication:-
-Infection.
-DIC
Septic abortion
It is a miscarriage that is complicated
with sepsis.
Clinical Presentation:-
-The Patient is very ill, febrile and
anemic.
-Sever abdominal tenderness.
-offensive vaginal discharge.
-Shock may be present either due to
bleeding or sepsis.
Leucocytosis and anemia
Septic abortion
Infection of the uterine cavity
following abortion leads to
SEPTIC ABORTION. Most cases
result from CRIMINAL
interference with non-sterile
instruments, but may follow
spontaneous miscarriage
Septic abortion cont…..
Pathology:
Spreading infection leads
rapidly to salpingitis, pelvic
peritonitis, pelvic cellulitis,
septicaemia and pyaemia.
Symptoms
1. A history of abortion, often
criminal.
2. Pelvic infection and septicaemia.
3. Fever with rigors.
4. Rapid thready pulse and low BP.
5. Dehydration.
Symptoms cont…..
6. Pelvic tenderness with foul
discharge from the uterus and
bleeding.
7. Neutrophil leucocytosis is found on
the blood count.
8. Reduced hemoglobin (anaemia).
Treatment
1. Admission to hospital
2. Blood culture
3. Hb, TWBC (and differential),
urine.
4. H.V.S.
5. Hydration with I.V. fluids and
blood transfusion if necessary.
Treatment cont……
6. Adequate doses of antibiotics
should be started at once: a
combination of amoxicillin,
Clindamycin, and Metronidazole
may be used. Change the
antibiotics according to culture
results.
Treatment cont…..
7. If the products of conception
are retained the uterus should
be evacuated. This should be
done at once if there is severe
bleeding, otherwise it is
preferable to wait to allow the
antibiotics to take effect.
Recurrent Miscarriage
Definition: (Three consecutive
spontaneous miscarriages)
Causes:
1. Chromosomal abnormalities.
(found in up to 3-5%)
2. Uterine abnormalities (bicornuate
and subseptate)
3. Polycystic ovaries.
Recurrent misc. causes cont….
4. Midfllicular LH/FSH defects
hypersecretion of LH
5. 15% of women with 1st trimester
recurrent miscarriage and 30% of
women with 2nd trimester misscarriage
may have Antiphospholipid antibodies
(APL).
6. 20% have thrombophilic defects.
7. Bacterial vaginosis.
8. Incompetent cervical os (2nd trimester
miscarriage)
Investigations
1. USS
2. HCG
3. Anticardiolipin antibodies.
(ACL)
4. Antiphospholipid antibodies (
APL).
.
Investigations cont….
5. Chromosome pattern of
wife and husband.
6. Screening for
Thrombophilia
7. H.V.S.
Investigations cont…..
8. Selective investigations:
Thyroid function tests ( TFT )
Renal function tests (RFT)
screening for Diabetes Mellitus
ARE DONE IF INDICATED.
9. TORCH have no value in the
investigations for Recurrent
miscarriage.
Treatment of Rec. misc.
1. Parenteral karyotyping
2. Surgical correction of uterine
abnormalities
3. Cervical circulage for int. os
incompetence
4. Medical treatment or laparoscopic
drilling for polycystic ovaries.
Treatment cont.
5. Thromboprophylaxis thrombophilia
using unfractionated heparin (UH), or
low molecular weight heparin (LMWH),
or low dose Aspirin.
6. High Vaginal swab (HVS) and treatment
according to the specific organism (e.g.
Metronidazole and/or Clindamycin
Cervical inCompetence
Mid trimester miscarriage
Cause
-Congenital.
-Acquired:
Instrumental delivery,
Excessive dilatation in D and C.
Cervical surgery
Treatment:-
Surgically by cervical cerclage
Induced abortion
1-illegal
2-therapeutic
INDUCED ABORTION

MEDICAL
HEART FAILURE.
RENAL FAILURE
CANCER + RADIATION
HEPATIC FAILURE
MALIGNANT
HYPERTENSION.
FETAL MALFORMATION
Mental diseases

RX:
MEDICAL BOARD.
CONSENT WRITTEN
DO IT IN A GENERAL
HOSPITAL
Diagnosis of Miscarriage
History:-
-amenorrhea , vaginal bleeding, abdominal pain and + ve
pregnancy test.
-Maternal age, medical disorder.
-Previous history of miscarriage. -
Examination:-
-General Examination.
-Speculum Examination.
-Ultra sound.
Laboratory investigation. -
-Full blood count.
-Blood group and Rh type.
-HCG. -
-Progestron
Management
(A) Surgical
(1) Vaginal evacuation
1- Suction
For 7 – 12 weeks gestation.
Procedure:-
-Evacuation of the bladder. -
-lithotomy Position .
-anaesthia.
-Sterilization
-Bimanual Examination
-Sims Speculum.
-Dilatation. -
-Suction: Canula and – ve pressure.
2- Dilatation and evacuation
The same as suction till the dilatation
of the cervix
Then:
-Ergometrin I/V.
-Evacuation: Ovum forceps.
-Curettage.
Complication of Vaginal
Evacuation
-Cervical laceration
-Cervical incompetence.
-Perforation of the uterus.
-Infection.
-Hemorrhage.
2) abdominal Evacuation
* hysterotomy
* Hysterectomy.
(B) Medical:
-Observation.
-Drug therapy: Prostaglandin.
-Psychological support. -
Follow up:-
Counseling the parent:
-Diagnostic evaluation.
-Treatment required.
-Prognosis and risk for future pregnancy.
Abortion نمتسبمينتسمنتمنتشسيمنبتشسبكمنئسكيمنشميس

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Abortion نمتسبمينتسمنتمنتشسيمنبتشسبكمنئسكيمنشميس

  • 2. Abortion (Miscarriage) Definition:- Termination of pregnancy before 24 weeks of gestation. *Occur in 10 – 20% of confirm pregnancy
  • 3. Causes (1) Chromosomal abnormality -( maternal age > 35 years old) -> 50% of Miscarriage in first trimester. e.g.: Trisomy (Down's Syndrome) Monsomy X (Turner's Syndrom Triploids and tetraploides
  • 4. (2) Immunological causes Anti phospho lipid syndrome. Anti cardio lipin anti bodies. (3) Infections CMV, Toxoplasmosis, syphilis and other febrile illness like Malaria. (4) Maternal diseases DM, HTN , Chronic renal diseases thyroid diseases.
  • 5. (5) Congenital of acquired abnormalities of female internal organ. (Double uterus, Septate uterus, cervical incompetence, uterine fibroid) (6) Drugs Cytotoxic drugs, caffeine, al cohol, tobacco and cocaine. (7) Over distension of the uterus eg: Multiple gestation. (8) Psychological disorders. (9)Hormonedeficiency.progesterone,leu tinizing hormone
  • 7. (1) Threatened miscarriage Definition:- painless vaginal bleeding accruing any time between implantation and 24 weeks gestation. * Cervix is closed Clinical Picture:- Signs and Symptoms of early pregnancy Mild vaginal bleeding. Pain slight or absent. Cervix is closed. Pregnancy test is + ve U/S show a living fetus.
  • 8. Management:- -Investigation:- HB% and urine general. Blood grouping and RH factor. U/S for fetus. -Bed rest. -Treat the cause if present. -Anti D if mother Rh – ve Prognosis:- - in 50% bleeding will stop and pregnancy will continue
  • 9. (2) Inevitable Miscarriage Clinical Picture:- -Vaginal bleeding is excessive with clots. -Supra pubic colicky pain radiated to the back. -Cervix is opened. Products of concepts may be felt in the cervical canal Management:- -Resuscitation (I/V Fluid, Blood transfusion and analgesia ) Ergometrine or Syntocinon. 1->12 weeks medical prostaglandins ,oxytocin 2-<12-surgical Evacuation of the uterus. -Anti D gamma globulin if mother RH – ve . -
  • 10. (3) In complete miscarriage Retention of a part of the product of conception inside the uterus. Clinical Picture:- -Excessive bleeding. -Abdominal pain. -Dilated cervix. -Product of conception in uterus, cervix or vagina. -The patient may be pale or shocked. -u/s show some material still remaining in the uterus. Management:- as the same as inevitable
  • 11. (4) Complete Miscarriage All the product of conception has been expelled from the uterus. Clinical Picture:- -Pain and bleeding are usually stop. -Cervix is close. -U/S show an empty uterus. - Management:- -No further treatment. -Anti D if mother RH – ve. -Anti biotic if needed. -observe the patient for 2 – 3 hours.
  • 12. (5) Missed miscarriage Is retention of dead fetus for 4 wks or more before 24weeks of gestation and failure of the uterus to expel it. Clinical Picture:- -History of normal pregnancy. -Painless recurrent Vaginal bleeding of dark brown blood. - loss of normal pregnancy symptoms. -Uterus doesn't increase in size or decrease. -No fetal movement and No FHS. Investigation:- -HCG levels drop in7-10 days and become ->ve -U/S show fetal death
  • 13. Treatment:- -Evacuation of the uterus either: Medically (Misoprostol 600 – 800 mg/vagina ) surgically: suction curettage. -Anti D if needed. -Anti biotic. Complication:- -Infection. -DIC
  • 14. Septic abortion It is a miscarriage that is complicated with sepsis. Clinical Presentation:- -The Patient is very ill, febrile and anemic. -Sever abdominal tenderness. -offensive vaginal discharge. -Shock may be present either due to bleeding or sepsis. Leucocytosis and anemia
  • 15. Septic abortion Infection of the uterine cavity following abortion leads to SEPTIC ABORTION. Most cases result from CRIMINAL interference with non-sterile instruments, but may follow spontaneous miscarriage
  • 16. Septic abortion cont….. Pathology: Spreading infection leads rapidly to salpingitis, pelvic peritonitis, pelvic cellulitis, septicaemia and pyaemia.
  • 17. Symptoms 1. A history of abortion, often criminal. 2. Pelvic infection and septicaemia. 3. Fever with rigors. 4. Rapid thready pulse and low BP. 5. Dehydration.
  • 18. Symptoms cont….. 6. Pelvic tenderness with foul discharge from the uterus and bleeding. 7. Neutrophil leucocytosis is found on the blood count. 8. Reduced hemoglobin (anaemia).
  • 19. Treatment 1. Admission to hospital 2. Blood culture 3. Hb, TWBC (and differential), urine. 4. H.V.S. 5. Hydration with I.V. fluids and blood transfusion if necessary.
  • 20. Treatment cont…… 6. Adequate doses of antibiotics should be started at once: a combination of amoxicillin, Clindamycin, and Metronidazole may be used. Change the antibiotics according to culture results.
  • 21. Treatment cont….. 7. If the products of conception are retained the uterus should be evacuated. This should be done at once if there is severe bleeding, otherwise it is preferable to wait to allow the antibiotics to take effect.
  • 22. Recurrent Miscarriage Definition: (Three consecutive spontaneous miscarriages) Causes: 1. Chromosomal abnormalities. (found in up to 3-5%) 2. Uterine abnormalities (bicornuate and subseptate) 3. Polycystic ovaries.
  • 23. Recurrent misc. causes cont…. 4. Midfllicular LH/FSH defects hypersecretion of LH 5. 15% of women with 1st trimester recurrent miscarriage and 30% of women with 2nd trimester misscarriage may have Antiphospholipid antibodies (APL). 6. 20% have thrombophilic defects. 7. Bacterial vaginosis. 8. Incompetent cervical os (2nd trimester miscarriage)
  • 24. Investigations 1. USS 2. HCG 3. Anticardiolipin antibodies. (ACL) 4. Antiphospholipid antibodies ( APL). .
  • 25. Investigations cont…. 5. Chromosome pattern of wife and husband. 6. Screening for Thrombophilia 7. H.V.S.
  • 26. Investigations cont….. 8. Selective investigations: Thyroid function tests ( TFT ) Renal function tests (RFT) screening for Diabetes Mellitus ARE DONE IF INDICATED. 9. TORCH have no value in the investigations for Recurrent miscarriage.
  • 27. Treatment of Rec. misc. 1. Parenteral karyotyping 2. Surgical correction of uterine abnormalities 3. Cervical circulage for int. os incompetence 4. Medical treatment or laparoscopic drilling for polycystic ovaries.
  • 28. Treatment cont. 5. Thromboprophylaxis thrombophilia using unfractionated heparin (UH), or low molecular weight heparin (LMWH), or low dose Aspirin. 6. High Vaginal swab (HVS) and treatment according to the specific organism (e.g. Metronidazole and/or Clindamycin
  • 29. Cervical inCompetence Mid trimester miscarriage Cause -Congenital. -Acquired: Instrumental delivery, Excessive dilatation in D and C. Cervical surgery Treatment:- Surgically by cervical cerclage
  • 31. INDUCED ABORTION  MEDICAL HEART FAILURE. RENAL FAILURE CANCER + RADIATION HEPATIC FAILURE MALIGNANT HYPERTENSION. FETAL MALFORMATION Mental diseases  RX: MEDICAL BOARD. CONSENT WRITTEN DO IT IN A GENERAL HOSPITAL
  • 32. Diagnosis of Miscarriage History:- -amenorrhea , vaginal bleeding, abdominal pain and + ve pregnancy test. -Maternal age, medical disorder. -Previous history of miscarriage. - Examination:- -General Examination. -Speculum Examination. -Ultra sound. Laboratory investigation. - -Full blood count. -Blood group and Rh type. -HCG. - -Progestron
  • 33. Management (A) Surgical (1) Vaginal evacuation 1- Suction For 7 – 12 weeks gestation. Procedure:- -Evacuation of the bladder. - -lithotomy Position . -anaesthia. -Sterilization -Bimanual Examination -Sims Speculum. -Dilatation. - -Suction: Canula and – ve pressure.
  • 34.
  • 35.
  • 36.
  • 37. 2- Dilatation and evacuation The same as suction till the dilatation of the cervix Then: -Ergometrin I/V. -Evacuation: Ovum forceps. -Curettage.
  • 38. Complication of Vaginal Evacuation -Cervical laceration -Cervical incompetence. -Perforation of the uterus. -Infection. -Hemorrhage.
  • 39. 2) abdominal Evacuation * hysterotomy * Hysterectomy.
  • 40. (B) Medical: -Observation. -Drug therapy: Prostaglandin. -Psychological support. - Follow up:- Counseling the parent: -Diagnostic evaluation. -Treatment required. -Prognosis and risk for future pregnancy.