Septic abortion (3)

septic abortion

1. SEPTIC ABORTION : WHERE WE STAND (CASE PRESENTATION) Dr Subhrata Nanda

2. Mrs S C, age 27yrs, from Puri admitted in labour room at 1am on 5/5/17 during emergency hours with complain of pain abdomen, vomiting, loose motion, yellow discolouration of body and eyes & decreased urination with reddish discolouration of urine since last 3 days

3. She is G4 P3 L3 at 19 wks of gestation went to a local hospital at Niali for MTP and MTP was tried . After 24hrs on 3/5/17 pt developed severe abdominal pain which subsided within 2hr without any medication. Then pt was referred to another hospital in B hubaneswar where evacuation was done at 10pm on 3/5/17. There perforation was detected by the surgeon and pt was put on conservative management.

4. On 4/5/17 pt developed pain & swelling of abdomen, jaundice, oliguria . She was referred to Hi-Tech medical college where she was diagnosed as septic shock in low condition. Due to unavailability of ICU, pt was referred here.

5. PATIENT CONDITION ON ADMISSION Pt was toxic, tachypnoeic , pale, icteric , pulse 130/min feeble, BP 80/40 mmhg , RR 30/min On P/A it was tense, tender, guarding +, rigidity +, bowel sounds sluggish On P/S vulval edema +, with muddy discharge, foley’s catheter insitu with 50ml of haemorrhagic urine On P/V Ut 16wks, soft and tender

6. Pt was shifted to ICU and pt condition deteriorated (fall in SpO2 urine output nil for 12hrs). USG done and the diagnosis ?uterine perforation, pelvic collection with B/L acute medical renal disease and B/L moderate pleural effusion. Decision for laparotomy was done to rule out bowel perforation. Laparotomy was done at 4pm on 5/5/17 in presence of surgeon.

7. Intra operative findings There was 200ml of yellowish dirty collection. No bowel perforation detected. There was a broad ligament hematoma on right side of size 5X 4cm. Uterus contour was intact. B/L tubes and ovaries healthy. Hematoma was drained and peritoneal lavage was done and intra peritoneal drain was left. Pt shifted back to ICU

8. LAB FINDINGS ON ADMISSION Hb- 7.4 gm% PCV – 22% T wbc – 21000/ cc TPC- 70000/cc PT- 22.2(↑) a PTT - 95.9(↑) INR- 1.32 Fibrinogen – 508 mg/dl Urea- 86mg/dl Creatinine- 2.3mg/dl Serum billirubin - 9.3mg/dl , D- 6.2mg/dl LFT- raised CBC notes- toxic change +, shift to left + Culture from urine, blood and peritoneal fluid shows no growth. Tracheal culture shows Acenobacter

9. IMPRESSION SEPTIC ABORTION WITH MODS ODS

10. MANAGEMENT Pt was in ICU Pt was on mechanical ventilation , crystalloids , Inotropes, BT, FFP, Platelet, Dialysis and broad spectrum antibiotics and other supportive measures. Then pt gradually improving and intraperitoneal drain was removed on 15/5/17 and extubated on 16/5/17 and due to shortness of breath on 17/5/17 she was on NIV.

11. CLINICAL FINDINGS ON 17/5/17 Pt is conscious and oriented and catheterized and on central venous line Dyspnoeic and on NIV Anaemic , no icterus , B/L pedal edema Vitals-pulse-134/min BP-149/84mmHg without ionotrops RR-46/min Temp-99.5F P/A-soft , parietal edema on flanks , BS present , wound healthy

12. LAB FINDINGS CBC-Hb-6.5gm%,PCV-21%,TPC-2.04 lakhs with toxic changes S.cretinine-4.1 mg/dl and B.urea-129mg/dl LFT-normal Hypoproteinemia

13. CLINICAL FINDINGS ON 18.05.2017

14. DISCUSSION

15. SEPTIC ABORTION -Any abortion associated with clinical evidences of infection of the uterus and its contents is called septic abortion. SEPTIC SHOCK/ENDOTOXIC SHOCK -Hypotension (systolic BP <90mm Hg) is due to sepsis resulting in derangements in cellular and organ system function. Hypotension persists in spite of adequate fluid resuscitation. Associated typically with septic abortion, chorioamnitis , pyelonephritis and rarely postpartum endometritis .

16. Clinical criteria of septic abortion Rise of temperature of atleast 100.4ºF (38.4 ⁰ C ) for 24 hours or more. Offensive or purulent vaginal discharge. Other evidences of pelvic infection – like lower abdominal pain and tenderness .

17. Mode of infection 80% cases source of infection is endogenous Micro-organisms responsible are : Anaerobic – Bacteroides group , Cl . Welchii , Anaerobic streptococci Aerobic – E.coli , klebsiella , Staph , psuedomonas , MRSA

18. Pathogenesis

19. Pathology 80% - Infection localised to conceptus . 15% - Endomyometritis , spread to parametrium , tube , ovaries 5% - Generalised peritonitis, endotoxic shock

20. Clinical Features Sick , anxious Temperature > 38 C Chills and rigor Persistent tachycardia > 90 bpm Hypothermia( endotoxic shock) < 36 C Abdominal or chest pain Tachypnoea > 20 breaths per minute Impaired mental state Diarrhoea and/or vomiting Renal angle tenderness

21. Clinical Features On Pelvic Examination : Offensive purulent vaginal discharge Uterine tenderness Boggy feel in POD (pelvic abscess)

22. CLINICAL GRADING OF SEPTIC ABORTION Grade I – Infection localised to uterus Grade II – Infection spread beyond uterus to parametrium , tubes , ovaries, pelvic peritoneum Grade III – Generalised peritonitis, endotoxic shock, jaundice , acute renal failure

23. Complications IMMEDIATE : Hemorrhage Injury Generalised peritonitis Endotoxic shock ARF Lungs – Atelectasis, ARDS Thrombophlebitis

24. REMOTE : Chronic debility Chronic pelvic pain, LBA Dyspareunia Ectopic pregnancy Secondary infertility Depression

25. PRINCIPLE OF MANAGEMENT OF SEPTIC SHOCK Appropriate supportive care Correction of hemodynamics Broad spectrum antibiotics Correction of acidosis Remove the source of sepsis

26. INDICATIONS OF SURGERY Injury to uterus Suspected bowel injury Presence of FB in abdomen Unresponsive peritonitis suggestive of collection of pus Septic shock not responding to conservative t/t Uterus is too big to be safely evacuated vaginally

27. PREVENTION Strengthening family planning practices Rigid enforcement of legalized abortion in practice and to curb the prevalence of unsafe abortion Proper antiseptic and aseptic measures

28. KIND REQUEST ON BEHALF OF SOCIETY THINK TWICE BEFORE SAYING NO BECAUSE A NO TODAY MAY FORCE YOU TO THINK EVERYDAY

29. 29 Thank you