Miscarriage

1. Miscarriage Done by : Samah Al Najjar Alaa Jamal abortion

2. Definition : • Is the expulsion or extraction of products of conception before fetal viability : before 24 weeks of gestation.

3. Incidence : • Is the commonest gynecological & obstetric disorder • About 15% pf clinically recognized pregnancies end in abortion ( this rise 30% if unrecognized pregnancies are included) • Most abortions occur between 8 and 12 weeks of pregnancy.

4. Types of abortion : • 1- Spontaneous abortion • - first trimester abortion • - second trimester abortion • 2- Legal abortion • -therapeutic abortion • 3- Illegal abortion

5. The Etiology for spontaneous abortion: • A- first trimester abortion • Fetal chromosomal abnormalities ( 50-70%) • An embryonic pregnancy – blighted ovum • Multiple pregnancy • Parental balanced translocation • Infections • Endocrine disorders ( Diabetes , thyroid disorders .. Etc • Uterine disorders : Uterine anomalies , submucus fibroid & Asherman’s syndrome. • Thrombophilia : congenital deficiency of protein C & S, & anti-thrombin III • Immunological disorders : Anticardiolipin syndrome & SLE • Cigarette smoking ,anesthetic agents , chemical agents. 11. Psychological disorders

6. Second trimester abortion : • Multiple pregnancy • Cervical incompetence ( Congenital and acquired ) • Uterince anomalies and submucous fibroid • Genital tract infection

7. Legal abortion : • Therapeutic abortion : defined as the termination of pregnancy for medical indications , including : • Medical illness in the mother in which continuation of the pregnancy has the potential to threaten the life or health of the mother is a factor . • If there is a genetic condition in the embryo or fetus which is incompatible with life ( sever case of certain genetic condition , sever case of profound mental impairment , cerebral hemispheres , anencephaly )

8. Legal termination of pregnancy When carried out with proper facilities, legal abortion has an extremely low mortality rate, being less than the mean death rate associated with pregnancy. The usual methods are vacuum aspiration, dilatation and curettage, or hysterotomy in later pregnancy. A few deaths are reported from time to time, the causes including: ■ pulmonary embolism from leg vein thrombosis ■ mishaps associated with anaesthesia ■ disseminated intravascular coagulation and cerebral damage ■ air embolism following vacuum aspiration ■ bleeding or infection, which failed to respond to treatment

9. Illegal abortion • This has a much wider range of causes. • The risks vary according to the skill, experience and facilities of the abortionist. When this is carried out by a doctor with aseptic and antiseptic methods, together with antibiotic cover if needed, the risk may be small compared with the crude methods of a lay person using makeshift instruments. The most common methods together with the associated dangers to health and life are as follows :

10. Illegal abortion • The intention is to disturb the pregnancy sac so that, once damaged, it will be expelled by uterine contractions • All manner of instruments have been used, from surgical dilators to bicycle spokes. • The dangers of such instrumentation are bleeding and infection. Perforation o f the wall o f vagina or uterus may cause severe bleeding. • Another less common danger o f the use of instruments (including syringes) is cervical shock. The mere act of dilating the cervix with an instrument in an unanaesthetized patient may trigger a vagal reflex, the efferent pathway being via the parasympathetic nervous system, causing a cardiac arrest. Instrumental Interference

11. Another crude method was to introduce a ‘tent’ into the cervical canal. This was a strip of substance that absorbed water and became greatly enlarged , The risks were perforation of the cervix and also infection . 2. Dilation of the cervix 3.Physical Violence Women anxious to lose their pregnancy have resorted to extremes of physical activity and even violence in efforts to dislodge the fetus. some unfortunate women went on to seek violent treatment from husbands or consorts. Punching and kicking of the abdomen were most common, and death from visceral rupture, such as liver, spleen or intestine

12. 4- INSUFFLATION OF AIR • A rubber pump, usually a Higginson enema syringe, is used to introduce fluid under pressure into the cavity of the uterus. This strips the chorionic sac from the wall of the uterus, exposing the placental bed. If sufficient detachment is achieved, then abortion will occur. • The main danger – part from the usual risks of bleeding and infection from damage to the tissues by the stiff nozzle – was air embolism

13. The suction method most often used in therapeutic abortion has also come to be used for illegal operations, mainly by medical or nursing personnel. The method is safe as long as aseptic methods are used, though, if evacuation is incomplete, some products of conception may be left behind that can form a nidus for infection. Whatever method is used to evacuate the uterus, the risk of haemorrhage or sepsis is always present. 5. Syringe aspiration Substances applied locally include phenols and Lysol, mercuric chloride, potassium permanganate, arsenic, formaldehyde and oxalic acid. All have their own dangers, both from local corrosion and systemic effects if absorbed. A necrotic pseudomembrane may form in the vagina and severe damage to the cervix may also ensue. 6. Drugs & chemicals

14. Pennyroyal, tansy, rue, savin, laburnum, colocynth, aloes, castor oil, nutmeg, hellebore, cantharides, cotton root, wintergreen and turpentine. Many of these may cause purging, gastrointestinal irritation and general illness if taken in quantity. Also Quinine can be dangerous, as the dosage required for any effect on the uterus is likely to cause cinchonism

15. This woman insufflated her uterus with a Higginson syringe and had time to clean up the equipment before collapsing with air embolism Burns from a hot-water bottle on the inner side of the upper thigh in an attempt to resuscitate the victim of a criminal abortion who died from air embolism.

16. THE AUTOPSY IN ABORTION DEATHS : • If death in pregnancy or criminal abortion is suspected, usual full autopsy with fullest possible history is required . a careful external examination must be carried out, noting especially: • 1- Abnormal coloration of the skin, such as in the bronzing of clostridialsepticaemia and the jaundice of liver damage. • 2- Signs and duration of pregnancy, such as abdominal swelling and breast changes. • 3- Signs of injury, including bruising or abrasion of the vulva from instrumentation, and vaginal bleeding or burns the abdomen . • 4- The vagina should be examined for signs of recent or current pregnancy, and attempted or successful recent abortion. • 5- Where any possibility of air embolism is considered, pre-autopsy radiology of the chest and abdomen must be performed

17. Complication of abortion : • 1. Hemorrhage • 2. Complication related to surgical evacuation • Uterine perforation • Cervical tear & excessive cervical dilation – which may lead to cervical incompetence • Infection which may lead to infertility and Asherman’s syndrome • 3. Rh-iso-immunisation if the anti-D is not given or if the dose is inadequte • 4. psychological trauma