Septic abortion

Pregnancy related clinical condition

1. Farjana Islam MC: 602 Shiblee Ahamed MC: 632 Septic Abortion Prepared By

2. A garments worker couple has 2 children and they do n 't want any more. Due to contraceptive failure, the women named Sabina became pregnant.

3. After that, they went to a village to an untrained dai and had an induced abortion.then Sabina started to develop lower abdominal pain, high grade fever,foul smelling vaginal discharge.

4. After 2 weeks,Sabina admitted to emergency department followed by ICU with features of shock ( low BP,Cold clammy skin,very low urine output. ) After 2 days of fighting Sabina died in ICU.

5. Abortion is defined as the spontaneous or induced termination of pregnancy before fetal viability (22 weeks). Abortion

6. Causes of Abortion:

7. Causes of Abortion:

8. Causes of Abortion:

9. Classification:

10. Septic Abortion: Any abortion associated with clinical evidences of infection of the uterus and its contents is called septic abortion.

11. 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.

12. Incidence Majority of cases, the infection occurs following illegal induced abortion but infection can occur even after spontaneous abortion.

13. 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

14. Pathology Infection begins as endometritis and involves the endometrium. If proper treatment is given It can resolve

15. If it is not treated properly The infection may spread further into myometrium, parametrium, uterine tubes ovaries and pelvic peritoneum In severe cases. there is generalized peritonitis, septicaemia and pyemia

16. Symptoms: Short period of amenorrho e a Offensive purulent per vaginal discharge. Fever with chills and rigor Diarrhoea

17. Symptoms: Vomiting Lower abdominal pain Regression of pregnancy symptoms.

18. Sign: Patient looks pale and toxic Persistent tachycardia › 90 beats/ min Tachypnea (RR) > 20/ min

19. Sign: Hypotension Temperature > 38°C chills and rigors Hypothermia (endotoxic shock <36°C)

20. On Per Abdominal Examination Uterine size variable (may be larger) Renal angle tenderness Abdominal distension

21. On per vaginal examination: External os → open Offensive purulent discharge Injury to the cervix or, vagina Foreign body inside the vaginal tract Uterine tenderness

22. Investigation: Routine investigations Special investigations

23. Investigations Routine investigations: Cervical or high vaginal swab for Culture Sensitivity of the microorganisms to antibiotics Smear for Gram stain

24. Routine Investigations Blood Hb % - May be low TLC - May increase ABO Rh Urine analysis and culture

25. 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

26. Blood: Culture: if associated with chills & rigors Serum electrolyte, C- reactive proteins, serum lactate Coagulation profile

27. Plain X ray:  Abdomen: suspected of bowel injury Chest: Pulmonary complications (Atelectasis)

28. Clinical Grading  Grade-l: The infection is localized in the uterus  Grade-Il: The infection spreads beyond the uterus to the parametrium, tubes and ovaries or pelvic peritoneum.  Grade-Ill: Generalized peritonitis and /or endotoxic shock or jaundice or acute renal failure. > Almost always associated with illegal induced abortion

29. Management General Management Grading Management

30. General Management Hospitalization Vaginal/ Cervical swab Vaginal Examination Overall Assessment Investigation Protocols

31. 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.

32. SPECIFIC TREATMENT Septic Abortion: Treatment depends on Grading In Grade - 1 (Infection confined to uterus) If in shock - Resuscitation Iv Triple Therapy Prompt Evacuation

33. SPECIFIC TREATMENT Grade - 2 (Pelvic Abscess)  Colpotomy with drainage of pus OR, Laparotomy.

34. Grade - 3 (Peritonitis) NPO (nothing per oral) NG suction IV nutrition IV Triple Therapy If patient not responding within 72 hours then Laparotomy followed by Peritoneal Lavage given.

35. Complications Immediate: Haemorrhage Pelvic abscess Generalised peritonitis FIG: Pelvic Abscess

36. Complications Immediate: Endotoxic shock Renal failure Thrombophlebitis DIC

37. Complications Late Infertility Ectopic pregnancy Pelvic inflammatory disease Tubo-ovarian mass.

38. Features of organ dysfunction in septic abortion: Persistent hypotension (SBP < 90 mmHg). Oliguria. Serum creatinine > 44.2 umol /L. Coagulation abnormalities (INR > 1.5).

39. Features of organ dysfunction in septic abortion: Thrombocytopenia. Hyperbilirubinemia. Pa02 < 40 kPa. Serum lactate ≥ 4.0 mmol/L. Thrombocytopenia

40. Indications of ICU management in septic abortion: (Plaat-2008) Cardiovascular Persistent hypotension. Persistently raised serum lactate (≥ 4.0 mmol/L). Respiratory Pulmonary oedema. Mechanical ventilation. Airway protection. Renal failure Renal dialysis. Neurological Impaired consciousness Miscellaneous Multiorgan failure. Hypothermia. Acidosis.

41. 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

42. Now what is your diagnosis?

43. Home Message

44. Reference Williams Textbook of Obstetrics, 24th edition DC Dutta's Textbook of Obstetrics, 10th edition Prof. Nurjahan /8th edition