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Clinical practice guideline Management of Septic Abortion

1. Post abortion infection ( ) 1.1 abortion 1.2 1.3 Spontaneous abortion , Criminal abortion legal abortion 48 % , 65 % 24 % ( 1 ) 2. Septic abortion definitions 2.1 Sepsis - Systemic responses Tachypnea ( RR > 20 / min ) , Tachycardia ( > 90 / min ) Hyperthermia , Hypothermia ( Rectal T > 38.3 or < 35.6 ) - Altered WBC > 12,000 cell / mm3 , < 4000 cell / mm3 2.2 Shock - Inadequate perfusion cells 2.3 Septic shock - sepsis Hypotension Organ dysfunction 2.4 Early septic shock - Septic conventional therapy 2.5 Severe septic shock - Lactic acidosis , oliguria , altered mental status - hypotension 1 . fluid vasopresser > 6 mcg / kg / min dopamine 3. (Pathophysiology) ( 2 ) - Abortion Ascending infection Retained Conception , operative trauma GI tract injury

Organisms proliferation ( E. coli , group A , B Streptococci , Bacteroides species ,Clostridium perfringens ) Toxins are released Endotoxins Gm -ve bacteria Exotoxins Gm + ve bacteria Toxin activate monocytes OR macrophages ( Cytokines production ) Cytokines are released ( TNF tumor necrosis Factor ) Interleukin 1 System activations occur ( TNF , IL -1 , IL -6 , IL 8 Complex cascades ) Complex cascades PGE2 , PGI2 , leukotricnes , Thromboxans Complenment C5a , Bradykinins GM - CSF , Myocardial depressant factors Organ dysfunction developes Shock developes with Poor tissue perfusion No Tx Refractory hypotension , Multiorgan systems failure Clinical manifestations ( 3,4 ) - Fever , Chill , malaise , Abdominal pain vaginal bleeding , Passage of placenta tissue , foul odor vaginal discharge , cervical vaginal laceration ,illegal abortion ) - Uterine tenderness adnexal tenderness

- Crepitus of the uterus ( Gas gangrene ) - Septic shock ( BP - , agitation , Toxic and disorientation ) Laboratory tests Purpose / Results 1. White blood cell counts initially decreased increase 2. Hematocrit Blood loss Plasma volume 3. Platelet count DIC *4. Fibrinogen and fibrin, degradation products DIC *5. Prothrombin time ( PT ) , Activated DIC Partial Thromboplastin time ( PTT ) Thrombin time ( TT ) *6. Arterial blood gases Respiratory alkalosis metabolic and respiratory acidosis *7. Hemodynamic measures homodynamic status Via Swan-Ganz catheter, CVP 8. Electrolyte acidosis 9. Glucose 10. Blood urea nitrogen ( BUN), Creatinin renal impairment 11. Endocervical gram stain , Source of infection *Hemoculture/sensitivity Organism response for septicemia *12. Ches X-ray Pneumonia ARDS *13. Abdominal film perforated viscous , foreign body *14. Electrocardiography arrhythmia or ischemia 15. Ultrasound abscess , foreign body uterine gangrene * (Severe septic shock) ( Treatment ) (5,6 ) - Septic Abortion Septic Abortion , sepsis or Septic shock or severe septic shock Septic Abortion (Local and systemic infection) - Holistic approach - Correct dehydration , raise Hematocrit

- Empirical antibiotics

First regimen PGS 2mu v q 4 hrs + Gentamicin 240mg v drip in hr OD + Metronidazole 500 mg v drip q 8 hrs Second regimen
infection , renal insufficiency

PGS 2mu v q 4 hrs + Ceftriazone 1 gm v q 12 hrs + Clindamycin 500 mg v q 8 hrs


- TT 0.5 cc. , TAT 3000 IU ( Skin test ) (Tetanus immunoglobulin)TIG 250 IU IM skin test Tetanus prophylaxis - D&C Infected uterine content induced abortion by medication ( Cytotec 1-2 vaginal suppository every 8 hours or syntocinon ) - Sensitivity - Counselling family planning Septic Shock A. Correct hemodynamic and metabolic abnormalities - Restore intravascular volume large catheter - Admit to ICU - Swan - Ganz Catheter monitor or Cut down restore Mean arterial pressure(MAP) = 60 mmHg at rest Pulmonary arterial wedge pressure(PAWP) = 14 18 mmHg. Central venous pressure(CVP) = 12-14 cm - Restore renal , Hepatic , Pulmonary and cardiac function - Correct Blood pressure inotropic drug Dopamine or dobutamine Dosage of dopamine ( Dopamine 1: 1) (1 amp=250mg/10ml) Dilute 2 ampule ( 500 mg ) in 5 % D/W 500 1000 mcg /ml dirp rate 2 . 5 mcg / kg / min (10mcdrop / min ) 50 kg. tritrate dosage to achieve adequate tissue perfusion max 20 mcg/ kg / min( 60 mcdrop/min)

Dosage of Dobutamine ( Dobutamine 1:1 ) concentration dopamine ( severe renal insufficiency ) - Digitalize Congestive heart failure - Steroid B. Treat Underlying infection - Initially , administer antibiotics covering all potential pathogens ( Mixed organisms ) - Determine source - Hysterectomy 1. appropriate empirical antibiotics 2. Perforation sepsis 3. Pelvic and adnexal abscess 4. Gas gangrene ( Clostridial necrotizing myometritis ) 5. Tetanus C. Support the respiratory system - Administor Oxygen - blood gas onset of respiratoy failure - Early use of mechanical ventilation with volume Cycled respirator D. Coagulation abnormalities E. keep records of medication and fluid F. Block effect of mediators of the sepsis cascades - RCT researchs ( Hyperimmune polyclonal , Monoclonal Ab to endotoxin , Mab to TNF 2 TNF -2 resceptor and IL 1 receptor ) Empirical antibiotics - culture and sensitivity - review antibiotic 24 - Meningitis blood- brain barrier - Drug Allergy - Drug resistant organism broad spectums - immunocompromised host

1980 Death rate 1 / 100,000 Physician skills , improved surgery methods legal Abortion Septic Abortion Asherman s syndrome , pelvic adhesion incompetent cervix , spontaneous abortion , Prematurity Low weight infant Underlying diseases Mortality of septicemia 40% , septic shock 50 80 % Prevention - Unwanted pregnancy - References 1. Centers for disease control Abortion Surveillance Annual summary 1978 U.S department of health and human services , 1980 ; 61. 2. Parrillo JE pathogenetic mechanisnm of septic shock N Eng J Med 1993 ; 328 1471 1477. 3. Bone RC. Toward on epidemiology and natural history of SIRS ( Systemic inflammatory response syndromic) , JAMA 1992 ; 268 : 3452 3455 4. Martin MA , Silverman HJ . Gram negative sepsis and the adult respiratory distress Syndrome Clin Infect Dis 1992 ; 14 . 1213 1218. 5. Glauser MP , Heumann D , Baumgartner JD . Pathogensis and potential strategies for prevention and treatment of septic shock : An update Clin infect Dis 1994 ; 18 supple S205 216. 6. Fisher CJ , Dhai naut JA , Opal SM , et al. Recombinant human interleulein 1 receptor antagonist in the treatment of patients with sepsis syndrome JAMA 1994 ; 271 : 1836-1843. 19 2547