1. Definition:

The expulsion or extraction of a fetus weighing less than 500gm. Or the termination of a fetus before 24wks of gestation with no evidence of life.

Incidence:

15% of clinically apparent pregnancies.

2. Etiology:

2.1. Fetal abnormality:

1. Chromosomal -commonest cause- (trisomy, monosomy, triploidy & tetraploidy)
2. Structural abnormality (neural tube defect)
3. Genetic

2.2. Endocrine abnormality:

1. Luteal phase inadequacy
2. High LH (PCO)
3. Poorly controlled diabetes
4. Thyroid diseases
5. SLE
6. Von willebrand disease
7. Wilson disease

2.3. Uterine abnormality:

1. Fusion defects (bicornuate or septate uterus)
2. Incompetent cervical os
3. Sub mucous fibroid
4. Asherman syndrome

2.4. Infections:

1. Pyrexial infections (malaria)
2. Other micro-organisms (Syphilis, rubella, variola, herpes simplex, toxoplasmosis, cytomegalovirus, brucella, mycoplasma…)

2.5. Poisons:

1. Cytotoxic drugs
2. High levels of lead
3. Quinine
4. Aniline
5. Smoking & alcohol

2.6. Immunological factors:

1. Lupus anticoagulant & anticardiolipin antibodies.
2. Rhesus incompatibility.

2.7. Trauma:

1. Amniocentesis
2. Pelvic surgery

3. Clinical types of miscarriage:

3.1. 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.

3.2. 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 12wks & uterine stimulation with oxytocin if the pregnancy is more than 12wks.

3.3. 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.

3.4. 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.

3.5. 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.

3.6. Recurrent miscarriage

• Three or more consecutive miscarriage.
• Occur in 1% of cases.

3.7. Septic abortion

3.7.1. Definition:

Any abortion associated with clinical evidence of infection of the uterus & it's contents.

3.7.2. 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:
  • 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.
  • 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.
  • 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.

3.7.3. Clinical features:

1. Pyrexia & tachycardia are early signs of infection.
2. Rigors suggest bacteremia.
3. A sub normal temperature is a serious sign & is most common seen with gas forming organisms.
4. The patient may be seriously ill with malaise, sweating, headache, joint pain.
5. Abdominal pain either localized or generalized.
6. Jaundice is a serious sign indicating hemolysis due to chemical or hemolytic infection.
7. Hypotension may be due hypovolumemia or endo-toxin or both.
8. Offensive vaginal discharges is present in most  cases & signify local infection & dead tissues.

3.7.4. 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 hypovolemia, end toxin, or drug toxicity.
• Hematuria result from glomerular damage and port wine urine is classic feature of severe clostridial infection.

3.7.5. Complications:

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.

Remote:

1. Chronic pelvic infection.
2. Infertility due to tubal blockage.

3.7.6. Investigations:

• Hb, Hct, blood grouping & cross matching & coagulation profile.
• WBC total & differential usually there is  gross leucocytosis. A low WBC 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.

3.7.7. 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:
  • Acute resuscitative measures have been achieved.
  • Antibiotic therapy has been established.
• In  the  absence of excessive bleeding or deterioration  in spite  of  the  above therapeutic measures an interval of 6hrs  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.