Septic Abortion
Download as PPTX, PDF64 likes39,847 views
This document discusses septic abortion, which occurs when an abortion is complicated by infection in the uterus or its contents. It defines septic abortion and outlines its causes, clinical presentation, investigations, management, and complications. Septic abortion is most commonly associated with illegal or unsafe induced abortions where proper aseptic techniques are not followed. Management involves controlling the infection with antibiotics, removing the source of infection, and providing supportive care. Treatment is based on clinical grading of the infection from Grade I (localized) to Grade III (generalized peritonitis or septic shock), with more aggressive management needed for higher grades.
Septic Abortion
- 2. Introduction Abortion: the spontaneous or induced termination of pregnancy before fetal viability WHO: Expulsion or extraction from its mother of an embryo or fetus weighing 500g or less when it is not capable of independent survival 2
- 3. Two types Spontaneous Threatened Inevitable Complete Incomplete Missed Septic- less common Induced Legal Illegal (unsafe) Septic-common 3
- 4. 4
- 5. Septic Abortion Any abortion associated with clinical evidences of infection of the uterus and its contents is called septic abortion Abortion usually considered septic if: rise of temperature of at least 100.4°F (38°C) for 24 hours or more offensive or purulent vaginal discharge other evidences of pelvic infection such as lower abdominal pain and tenderness 5
- 6. Incidence 10% of abortions requiring admission to hospital are septic Most of them are associated with incomplete abortion Majority of cases the infection occur following illegally induced abortion Can also occur following spontaneous abortion 6
- 7. Association of sepsis in illegally induced abortions Proper antiseptic and asepsis are not taken Incomplete evacuation Inadvertent injury to the genital organs and adjacent structures, particularly the bowels 7
- 8. Mode of infection Microorganism involved are normal vaginal floraAnaerobes Aerobes Bacteroides group (fragilis) Escherichia coli , Klebsiella Anaerobic Streptococci Staphylococcus, methicillin resistant staphylococcus aureus (MRSA) Clostridium welchii Pseudomonas Tetanus bacillus Group A beta Hemolytic Streptococcus 8
- 9. Pathology In 80% of the cases; organisms are endogenous in origin. Infection is localized to the conceptus No myometrial involvement In 15 % cases Infection produce localised endomyometritis In 5 % cases Generalized peritonitis and/or endotoxic shock Severe necrotizing infections and toxic shock syndrome caused by group A streptococcus- S. pyogenes 9
- 10. Clinical Features Depends on severity and extent of infection Sick & anxious Temperature > 38°C Chills and Rigor (S/0 Bacteremia) Hypothermia < 36°C (S/0 Endotoxic shock) Persistent tachycardia ≥ 90 bpm Tachypnea >20/min Impaired mental state Abdominal or chest pain Diarrhea & vomiting Renal angle tenderness 10
- 11. Pelvic examination Offensive purulent vaginal discharge Uterine tenderness Boggy feel in Pouch of Douglas (Pelvic Abscess) 11
- 12. Clinical grading Grade–I: The infection is localized in the uterus Grade–II: The infection spreads beyond the uterus to the parametrium, tubes and ovaries or pelvic peritoneum Grade–III: Generalized peritonitis and/or endotoxic shock or jaundice or acute renal failure. almost always associated with illegal induced 12
- 13. Investigations Routine investigations: Cervical or high vaginal swab for culture in aerobic and anaerobic media sensitivity of the microorganisms to antibiotics smear for Gram stain Blood- Hb, TC, ABO, Rh Urine analysis and culture 13
- 14. Special Investigations Ultrasonography of pelvis and abdomen: Intrauterine retained product of conception Physometra Foreign body (intrauterine or intra-abdominal) Free fluid in peritoneal cavity or pouch of Douglas Blood: Culture: if associated with chills & rigors Serum electrolyte, C- reactive proteins, serum lactate Coagulation profile Plain X ray: Abdomen: suspected of bowel injury Chest: Pulmonary complications (Atelectasis) 14
- 15. Complications Immediate: Hemorrhage- abortion process or injury inflicted during the interference Injury to the uterus and also to the adjacent structures particularly gut Spread of infection leads to: Generalized peritonitis the uterine tubes perforation of the uterus bursting of the micro abscess in the uterine wall Injury to the gut 15
- 16. Endotoxic shock—mostly due to E. coli or Cl. welchii infection Acute renal failure—patchy cortical necrosis or acute tubular necrosis Cl. Welchii Thrombophlebitis 16
- 17. Remote The remote complications include Chronic debility Chronic pelvic pain and backache Dyspareunia Ectopic pregnancy Secondary infertility due to tubal blockage and Emotional depression 17
- 18. Prevention To boost up family planning acceptance to prevent unwanted pregnancy To take antiseptic and aseptic precautions (internal examination or operation) Encourage abortion in legally practicing institutes only 18
- 19. Management General Management Grading Management 19
- 20. General Management Hospitalization Vaginal/Cervical swab Vaginal Examination Overall assessement Investigation protocols 20
- 21. Principle of Management To control sepsis. To remove the source of infection. To give supportive therapy. (In order to bring back to normal homeostatic & cellular metabolism) To assess the response of treatment. 21
- 22. Grading Management Grade I: Drugs: Antibiotics Prophylactic Antigas gangrene serum 8000 units and 3000 units of Antitetanus serum IM Analgesics & Sedatives Blood transfusion. Evacuation of uterus: Excess of bleeding is an indication 22
- 23. Antimicrobial Therapy: Piperacillin-Tazobactam or Carbapenem+Clindamycin (IV)- broadest range of microbial coverage Piperacillin-tazobactam & carbapenems Vancomycin or teicoplanin Clindamycin Gentamycin (3-5 mg/kg– single dose) Co- amoxiclav Metronidazole 23
- 24. Grading Management Grade II: Drugs: Antibiotics Prophylactic Antigas gangrene serum Analgesics & Sedatives Blood transfusion more needed than in Grade I. Clinical monitoring: Note pulse Respiration Temperature Urinary output Progress of pain, tenderness mass in lower abdomen CVP greater than 8 mm Hg 24
- 25. Grading Management Grade II: a) Evacuation of the uterus: Evacuation withheld for at least 48 hrs. When infection is controlled and localized. But excessive bleeding is an indication. b) Posterior colpotomy: If infection localized in POD, pelvic abscess formed. Causes Spiky rise in temperature Rectal tenesmus Boggy mass felt through post. fornix 25
- 26. Grading Management Grade III: Antibiotics as in Grade I & II. Clinical monitoring as in Grade II. Supportive therapy: Treat generalized peritonitis By gastric suction Intravenous crystalloids infusion Management of Endotoxic shock/ Renal Failure Features of Organ Dysfuction carefully guarded. May need Intensive Care Unit Management Active Surgery 26
- 27. Tissue perfusion Features of Organ Dysfunction Persistent hypotension (SBP < 90 mm Hg) PaO2 : <40 kPa Serum Lactate ≥ 4 mmol/L Oliguria Serum Creatinine > 44.2 umol/L Coagulation abnormalities (INR > 1.5) Thrombocytopenia Hyperbilirubinemia 27
- 28. CVS • Persistent Hypotension • Persistent raised serum lactate (≥ 4 mmol/L) Respi • Pulmonary edema • Mechanical Ventilation • Airway protection Renal • Renal Dialysis Neurological • Impaired consciousness Miscellaneous • Multiorgan failure • Hypothermia • Acidosis Indication for ICU Management 28
- 29. Active Surgery Indications: Injury to uterus. Suspected injury to bowel. Presence of foreign body in abdomen Sonography/ Xray / felt through fornix on PV Unresponsive peritonitis s/o collection of pus. Septic shock/Oliguria not responding to conservative treatment. Uterus too big to safely evacuated per vaginum. 29
- 30. References Williams Textbook of Obstetrics, 24th edition DC Dutta’s Textbook of Obstetrics, 8th edition 30
- 31. 31
Editor's Notes
- #9: Gram-negative organisms are—E. coli, Pseudomonas, Bacteroides, etc. Gram-positive organisms are—Staphylococci, anaerobic Streptococci, Cl. welchii, Cl. tetani, etc.
- #14: USG to detect intrauterine retained products of conception, physometra, foreign body—intrauterine or intra-abdominal, free fluid in the peritoneal cavity or in the pouch of Douglas.
- #15: USG to detect intrauterine retained products of conception, physometra, foreign body—intrauterine or intra-abdominal, free fluid in the peritoneal cavity or in the pouch of Douglas.
- #21: Hospitalization necessary for all septic cases Vaginal swab for culture drug sensitivity & gram stain Vaginal exam done to note state of abortion & extension of infection Investiga
- #26: A colpotomy is a type of incision that is made in the back wall of the vagina. During a tubal ligation, your doctor can use a colpotomy (also known as a vaginotomy) as one of the ways to reach your fallopian tubes