septic abortion casepresetation , COMPREHENSIV ABORTION CARE

septic abortion casepresetation

1. Case Presentation – septic abortion Presenter- Dr Janhavi Dhakate Junior resident Obstetrics and gynaecology Moderator – Dr Saswati Tripathy HOD and professor Obstetrics and Gynaecology AIIMS Guwahati Co-Moderator - Dr Anamika Baruah Senior Resident Obstetrics and Gynaecology AIIMS Guwahati

2. Patient Particulars Name : Mrs Maina Das Age : 27 years Obstetric Score : P1L1A2 LMP : 22/06/24 Occupation : Homemaker W/O : Mr Kankan Kalita Religion : Hindu Resident of : Molong , Dhopatari , Athiabari , Kamrup , Assam, PIN- 783346 Mobile No: 9394095743 Socioeconomic Status : Lower Middle Class Date of Admission : 3 rd September 2025 Date of Examination : 3 rd September 202 5

3. Chief Complaints Increased bleeding per vaginum since morning Pain in lower abdomen since morning Bleeding per vaginum on and off for last 20 days

4. History of present illness The patient performed a urine pregnancy test (UPT) at home after a two-week missed period, which came to be positive . She subsequently underwent a medical termination of pregnancy (MTP) on 8th August 2025 without consulting any doctor . Following the MTP, she experienced per vaginal bleeding lasting for 6–7 days, using approximately 4-5 pads per day. The bleeding was associated with passage of clots and cramping lower abdominal pain, which was relieved with medication. She did not notice the passage of any fleshy mass during this period. After the initial bleeding subsided, she continued to experience intermittent vaginal bleeding, which reduced in intensity with medication. However, she also reported the passage of excessive, foul-smelling vaginal discharge during this time. On 3rd September 2025, the patient experienced a sudden episode of heavy vaginal bleeding, with passage of large clots and the need for frequent pad changes. This was accompanied by severe abdominal pain, prompting her to seek emergency medical attention at AIIMS Guwahati. She denies any history of fever, loss of consciousness, or syncopal episodes .

5. Negative history No h/o fever, chills and rigors No h/o dysuria, urinary retention No h/o vomiting or loose stool No h/o sore throat ,tonsillitis, URTI No h/o myalgia No h/o loss of consciousness

6. Menstrual History Attained menarche at 12 years of age LMP : 22/06/24 Her previous menstrual cycles were regular (28 ± 2 days) with a duration of 4- 5 days with average flow (~2- 3 pads/day), with no h/o dysmenorrhea o r passage of excessive clots or intermenstrual bleeding

7. Obstetric History P1 L1 A2 Married life – 5 years P1- Girl, 2 years old, LSCS,CDMR , alive and well, birthweight- 3.2 kg A1- Induced abortion , followed by D & E, at 2 months of amenorrhea, 1 years ago A2- Induced abortion , MTP intake, not followed by DnE ,at 1.5 month amenorrhea, 20days back

8. Past Medical and Surgical History Not a known case of DM, HTN, t hyroid disorder, asthma or any chronic illness. No h/o any surgical intervention in the past

9. Personal History Dietary History: The patient is a non- vegetarian by diet, her calorie intake in the last 24 hours was 1950 kcal; Addiction History: Non- smo ke r , Non-alcoholic Bowel and bladder habit - Normal Sleep and appetite- Normal Drug a ll er g y . – Not known

10. Family History No h/o heart disease, tuberculosis, hypertension, diabetes or any other disease

11. General Examination Patient well oriented to time, place and person. Built- Average Height- 148 cm, weight - 47.6 kg, BMI - 21.5 kg/m 2 Vitals Pulse - 101 /min , right radial pulse, regular, normovolumic , with no radio- radial or radio femoral d e l a y . BP - 90/70 mm Hg RR - 18/min Temperature - 98.3 degrees F (afebrile )

12. General Examination Pallor (+) Icterus (-) Clubbing (-) Cyanosis (-) Lymphadenopathy (-) Pedal Edema (-)

13. Systemic Examination CNS - Well- oriented to time, place and person, GCS-E4V5M6 CVS - S1, S2 heard. No murmur heard. Respiratory System- B/L vesicular sounds heard with no added sounds

14. Per Abdominal Examination On inspection-Umbilicus- central , No venous engorgement, visible pulsation or peristalsis seen.All hernial sites intact.transverse suprapubic scar seen On palpation- Soft, tenderness present in suprapubic region , no guarding or rigidity

15. Per Speculumand Vaginal Examination p/s- mild bleeding seen admixed with foul smelling discharge, os open Os open, product of conceptus felt through os cervix soft Uterus bulky, anteverted , bilateral forniceal tenderness present

16. Provisional Diagnosis 27 Y/O P1L1A2 WITH INCOMPLETE SEPTIC ABORTION WITH ANEMIA

17. Investigations Blood Group B + ve HIV I and II NR HBsAg NR Anti HCV NR VDRL   NR CBC 03 /0 9 /25 04 /0 9 /25 (post- S&E ) Haemoglobin TLC Platelet APTT   7.3 g/ dL 24.5 x10 9 /L 311 x10 9 22.6 seconds 8.5 g/ dL 9.9 x10 9 /L 272 x10 9 /L Emergency USG pelvis ( 03 /0 9 /25) uterus normal in size.heterogenous content seen in uterine cavity with no vascularity measuring 3.2*2.9*2.1 cm .B/l adnexa normal F/S/O RPOC Anemia Profile DTIBC T. Saturation Ferritin S Iron Folate Vit . B12 PBS (7/9/25)         (04/09/25) 353 mc g/ dL 15 % 1 7.3 ng/ dL 51 mcg/ml 2.82 ng/ml 246 pg /ml   Microcytic hypochromic RBCs showing mild anisocytosis with few polychromatophill

18. Final diagnosis 27 Y/O P1L1A2 WITH INCOMPLETE SEPTIC ABORTION WITH MODERATE ANEMIA

19. Course during hospital stay Patient underwent suction evacuation on 3 rd September 2025 Sample of RPOC sent for culture sensitivity and HPE 1 unit prbc transfused on 03/09/25 Inj ceftriaxone 1 g and inj metronidazole 500 mg given for 5 days

20. Septic abortion Any abortion associated with clinical evidence of infection of the uterus and its contents is called septic abortion Clinical criteria- 1..rise in temperature of at least 100.4 F for 24 hours or more 2.Offensive purulent vaginal discharge 3.Lower abdominal pain and tenderness Incidence-about 10 of abortion requiring hospitalization are septic – majority of he cases infection occurs following illegal induced abortions

21. Grades of septic abortion Grade I- loacalised within the uterus Grade II - involvement of the parametrium , adnexa and other pelvic structures Grade III- general peritonitis,acute renal failure,endotoxic shock

22. Maternal Sepsis (RCOG 2024) “ a life-threatening condition defined as organ dysfunction re- sulting from infection during pregnancy, childbirth, post- abortion,or postpartum period.” Septic shock is now described as a clinical construct of sepsis with persisting hypotension requiring vasopressors to maintain an adequate blood pressure (MAP 65 mm Hg or more ), alongside a persistent serum lactate (either venous or arterial) level more than 2 mmol /L despite adequate volume resuscitation

23. Risk factors (RCOG)

24. Etiology

25. Clinical signs and symptoms

26. Investigations Blood group and cross match Complete blood count Liver function test, kidney fuction test, coagulation profile C- reactive protein Arterial blood gas analysis- serum lactate levels Blood culture- 1 bottle each for aerobic ad anaerobic culture Urine route and microscopy, urine culture sensitivity Ultrasound abdomen and pelvis Chest x ray High vaginal swab

27. Assessment

28. Management

29. Antibiotic administatration For empirical therapy of life-threatening sepsis, a combination of either piperacillin/ tazobactam or meropenem (for Gram nega-tive cover) plus clindamycin (for Gram positive and anaerobic or- ganisms ) provides very broad cover, but lacks guaranteed MRSA cover . Therefore , if there is any suspicion of MRSA, addition of vancomycin is advisable .

30. Management ( contd.) Suction and evacuation Laparoscopy/ laprotomy

31. Thank you

32. Abortion Scenario in the Country

33. Policies for Safe Abortion Care ( A) Integrated strategic approach under the Reproductive, Maternal, Newborn, Child and Adolescent Health (RMNCH+A ) (B) Establishing CAC service delivery ( C) Generating awareness

34. Who can terminate the pregnancy

35. When Can a Pregnancy be Terminated? A pregnancy can be terminated by a registered medical practitioner upto 20 weeks of gestation if : l The continuation of pregnancy involves a risk to the life of the pregnant woman or causes grave injury to her physical or mental health The anguish caused by the unwanted pregnancy in the following situations is presumed to cause grave injury to the mental health of the pregnant woman: rape or incest , failure of any device or method used by any woman or her partner for the purpose of limiting the number of children or preventing pregnancy There is a substantial risk that, if the child was born, would suffer from such physical or mental abnormalities as to be seriously handicapped

36. When Can a Pregnancy be Terminated? A pregnancy can be terminated by a registered medical practitioner between 20 - 24 weeks of gestation for the following special categories of women: a . survivors of sexual assault or rape or incest; b . minors; c . change of marital status during the ongoing pregnancy (widowhood and divorce ); d . women with physical disabilities [major disability as per criteria laid down under the Rights of Persons with Disabilities Act, 2016 (49 of 2016 )] e . mentally ill women including mental retardation; f . the foetal malformation that has substantial risk of being incompatible with life or if the child is born it may suffer from such physical or mental abnormalities to be seriously handicapped; and g . women with pregnancy in humanitarian settings or disaster or emergency situations as may be declared by the Government.

37. Where Can a Pregnancy be Terminated? MTP can be performed at the following places: A hospital established or maintained by the Government A place approved by the Government or a District Level Committee (DLC) constituted by that Government with the Chief Medical Officer (CMO) as the Chairperson of the Committee It should be noted that the DLC shall consist of not less than three and not more than five members, including the Chairperson.

38. Documentation/Reporting of MTP Cases It is mandatory to fill and record information for abortion cases, performed by any method, in the following forms: 1 . Consent Form: Form C – for consent by the woman/guardian before the CAC procedure 2 . RMP Opinion Form Form I*** (for MTP upto 20 weeks by one RMP) Form E (for MTPs between 20 – 24 weeks by two RMPs) , Form D (for MTPs beyond 24 weeks by Medical Board members) 3. Form II*** – Monthly Reporting Form (to be sent to the district authorities) 4 . Form III*** – Admission Register for case records

39. Medical Methods of Abortion for Termination of Pregnancy in the First Trimester

40. Expected Side-effects Nausea/vomiting/ diarrhoea (gastrointestinal symptoms): Feeling of warmth and chills: It is usually short-lived and resolves spontaneously. Ibuprofen given for pain relief also takes care of fever, but if the temperature exceeds 100.4°F (38°C) or persists for several hours despite antipyretics, infection should be ruled out. Antipyretics such as Paracetamol can be given, if required Headache , dizziness and fatigue: Headache is treated with non-narcotic analgesics and mild dizziness of short duration is managed by hydration. Advise the woman to take plenty of fluids, rest and exercise caution while changing position

41. Vacuum Aspiration Techniques in the First Trimester a safe and simple technique for the termination of pregnancies up to 12 weeks of gestation/uterine size

42. Methods of Second Trimester Pregnancy Termination A) Surgical methods ( i ) (Dilatation and Evacuation (D&E) ( ii) Hysterotomy (B) Medical methods ( i ) Mifepristone and misoprostol regime ( ii) Misoprostol alone regime

43. Complications of surgical abortion

44. Delayed complications

45. Delayed complications of a bortion ( i ) Menstrual disturbances Amenorrhoea and hypomenorrhoea may result from varying degrees of intrauterine adhesions ( Ashermann’s syndrome). (ii) Infertility may result from tubal factor (closure or distortion) due to post- abortal infections or uterine factor due to endometrial trauma or infection. ( iii) Recurrent abortion Late (mid-trimester) abortion can occur due to cervical incompetence as a result of injury from forceful dilatation to the cervix. Cervical incompetence must be anticipated, diagnosed early and be managed by cerclage. ( iv) Ectopic pregnancy Tubal distortion due to post- abortal infection may increase the risk of tubal ectopic pregnancy . (v) Obstetric complications may rarely occur during future pregnancies. Adherent placenta and uterine rupture may result from a previous undiagnosed perforation. ( vi) Psychosomatic conditions

46. Post Abortion Contraceptive methods

47. Thank you