Septic Abortion

Septic abortion along with it's causes and complications

1. Septic Anish Dhakal (Aryan)

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

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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 flora Anaerobes 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 abortion 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, 24 th edition DC Dutta’s Textbook of Obstetrics, 8 th edition 30

31. Thank You !!! 31