Septic abortion for Revision.pptx

reproductive health

1. Septic abortion Revision for members Dr. Lawrence Buadi GARH

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

3. Introduction GMHS 2017-27% used Non-medical methods for abortion Abortion public health concern in low- and middle-income countries Abortion one of the main contributors to MMR in Ghana High fertility rate, low contraceptive usage and obstacles to safe abortion care contributes significantly to unsafe abortion and therefore bad outcomes

4. Types of Abortion Spontaneous Complete Incomplete Missed Threatened Inevitable Septic- less common Induced Legal Illegal(unsafe) Septic-common

5. Types of spontaneous abortion Inevitable: intrauterine gestation with cervical dilatation and vaginal bleeding Incomplete: cervix opened and some poc passed Complete: pregnancy has been expelled completely Missed: embryo never formed/demise, but uterus has not expelled sac Septic: missed/incomplete becomes infected

6. 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 38°C for 24 hours or more Offensive or purulent vaginal discharge Other evidences of pelvic infection such as lower abdominal pain and tenderness

7. Epidemiology of septic abortion 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/unsafe abortion Can also occur following spontaneous abortion

8. Association of sepsis in illegally induced abortion Proper antiseptic and asepsis are not adhered to Incomplete evacuation Inadvertent injury to the genital organs and adjacent structures, particularly the bowels

9. Mode of infection(organism involved (normal flora) Anaerobes Clostridium welchii Anaerobic Streptococci Tetanus bacillus Bacteroides group (fragilis) Aerobes Escherichia coli , Klebsiella Staphylococcus, methicillin resistant staphylococcus aureus (MRSA) Pseudomonas Group A beta Hemolytic Streptococcus

10. Pathophysiology Sepsis begins from vaginal bacteria invasion of uterus Bacteria gains access into maternal intervillous space of placenta Bacteremia occurs in the intervillous space in >60% cases of septic abortion Presence of toxins by some bacteria plus overwhelming immune response to infection systemic dx and multi-organ failure Prolonged presence of infected POC invasion of decidua of the endometrium myometrium and outside of uterus

11. 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

12. Clinical Grading Grade–I: The infection is localized to 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

13. Clinical features Depends on severity and extent of infection Sick & anxious Temperature > 38°C Chills and Rigor (S/0 Bacteremia) Hypothermia < 36°C ( Endotoxic shock) Persistent tachycardia ≥ 90 bpm Tachypnea >20/min

14. Clinical features Impaired mental status Abdominal or chest pain Diarrhea & vomiting Renal angle tenderness Pelvic examination Offensive purulent vaginal discharge Uterine tenderness Boggy feel in Pouch of Douglas (Pelvic Abscess)

15. Investigation 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- FBC, ABO & Rh Urine analysis and culture

16. Special investigations Pelvic/Abdominal Usg scan: Intrauterine RPOC Pyometria 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)

17. 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

18. Complications Endotoxic shock—mostly due to E. coli or Cl. Welchii infection Acute renal failure—patchy cortical necrosis or acute tubular necrosis Cl. Welchii Thrombophlebitis

19. Complications The remote complications include Chronic debility Chronic pelvic pain and backache Dyspareunia Ectopic pregnancy Secondary infertility due to tubal blockage and Emotional depression

20. Prevention To boost up family planning acceptance to prevent unwanted pregnancy To take antiseptic and aseptic precautions (internal examination or operation) Encourage abortion in legal/safe situations – CAC Appropriate referral systems (conscientious objection)

21. Management General Management Grading Management

22. Management General management Hospitalization Vaginal/Cervical swab Vaginal Examination Overall assessment Investigation protocols

23. 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

24. 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: Excessive bleeding is an indication

25. Grading management 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

26. Grading management Grade II: Dru gs: Antibiotics Prophylactic Antigas gangrene serum Analgesics & Sedatives Blood transfusion more needed than in Grade I Clinical monitoring : Vitals Urinary output Progress of pain, tenderness mass in lower abdomen CVP greater than 8mmHg

27. 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

28. 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 infusio n

29. Grading management Management of Endotoxic shock/ Renal Failure Features of Organ Dysfunction carefully guarded May need Intensive Care Unit Management Active Surgery

30. Features of Organ Dysfunction Persistent hypotension (SBP < 90 mm Hg) PaO2 : 44.2 umol /L Coagulation abnormalities (INR > 1.5) Thrombocytopenia Hyperbilirubinemia

31. Indication for ICU Management CVS Persistent hypotension Persistent elevated serum lactate RESPIRATORY Pulmonary edema Mechanical ventilation Airway protection RENAL Dialysis NEUROLOGICAL Impaired consciousness MISCELANEOUS Multi organ failure Acidosis Hypothermia

32. Active surgery Indications: Injury to uterus Suspected injury to bowel Presence of foreign body in pelvis/abdomen: Sonography/ Xray / felt through fornix on PV Unresponsive peritonitis as a result of pus collection Septic shock/Oliguria not responding to conservative treatment. Uterus too big to safely evacuate per vaginum

33. References Williams Textbook of Obstetrics, 24th edition DC Dutta’s Textbook of Obstetrics, 8th edition Anish Dhakal (Aryan) PPT Treating Spontaneous and Induced Septic Abortions (David A. Eschenbach , MD), Clinical Expert Series. Septic abortion: a review of social and demographic characteristics, (Henry Osazuwu et,al . 2006) Experiences of women seeking post abortion care services ina regional hospital in Ghana (Kenneth Setorwu Adde et,al ., 2021)