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
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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)
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3.  --poorly controlled diabetes.
 --thyroid diseases.
 --SLE.
 --von willebrand disease.
 --wilson disease
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4.  3)uterine abnormality;-
 --fusion defects
(bicornate or septate uterus)
 --incompetent cervical os.
 --sub mucous fibroid.
 --asherman syndrome
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5.  Infections;-
 --pyrexial infections (malaria)
 --other micro-organisms.
 Syphilis, rubella, variola, herpes simplex,
toxoplasmosis, cytomegalovirus, brucella,
mycoplasma& others
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6.  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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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
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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.
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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.
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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
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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.
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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.
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13.  --three or more consecutive miscarriage.
 -occur in 1% of cases.
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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
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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
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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.
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17.  --E-coli.
 --streptococci (hemolytic, non hemolytic, &
anaerobic) .
 --staphylococcus auras.
 --bacteroids.
 --klebsiella.
 --proteus.
 --pseudomonas.
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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
 .
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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.
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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

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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
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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
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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
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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
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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;--
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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.
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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.
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