SEPTIC

Anish Dhakal
(Aryan)
 Introduction
2

 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
 Two types
3

 Spontaneous  Induced
 Threatened  Legal

 Inevitable  Illegal (unsafe)

 Complete  Septic-common

 Incomplete

 Missed

 Septic-
less
common
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 Septic Abortion
5

 Any abortion associated with clinical

evidences of infection of the uterus and its
contents is called septic abortion
 Abortion usually considered septic if:
 riseof 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
 Incidence
6

 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 abortion
 Can also occur following spontaneous abortion
 Association of sepsis in illegally
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induced abortions
 Proper antiseptic and asepsis are not taken
 Incomplete evacuation
 Inadvertent injury to the genital organs and
adjacent structures, particularly the bowels
 Mode of infection
8

Microorganism involved are normal vaginal

flora
Anaerobes Aerobes
Bacteroides group Escherichia coli ,
(fragilis) Klebsiella
Anaerobic Streptococci Staphylococcus,
methicillin resistant
staphylococcus aureus
(MRSA)
Clostridium welchii Pseudomonas
Tetanus bacillus Group A beta Hemolytic
Streptococcus
 Pathology
9

 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
 Clinical Features
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Depends on severity and extent of infection

 Sick & anxious

 Temperature > 38°C

 Chills and Rigor (S/0 Bacteremia)

 Hypothermia < 36°C (S/0 Endotoxic shock)

 Persistent tachycardia ≥ 90 bpm

 Tachypnea >20/min

 Impaired mental state

 Abdominal or chest pain

 Diarrhea & vomiting

 Renal angle tenderness

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 Pelvic examination
 Offensive purulent vaginal discharge
 Uterine tenderness

 Boggy feel in Pouch of Douglas (Pelvic Abscess)

 Clinical grading
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 Grade–I: The infection is localized in 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
 Investigations
13

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- Hb, TC, ABO, Rh

 Urine analysis and culture

 Special Investigations
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 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
 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)
 Complications
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 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
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 Endotoxic shock—mostly due to E. coli or Cl.

welchii infection
 Acute renal failure—patchy cortical necrosis
or acute tubular necrosis Cl. Welchii
 Thrombophlebitis
 Remote
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 The remote complications include

 Chronic debility
 Chronic pelvic pain and backache

 Dyspareunia

 Ectopic pregnancy

 Secondary infertility due to tubal blockage and

 Emotional depression
 Prevention
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 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
 Management
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 General Management
 Grading Management
 General Management
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 Hospitalization
 Vaginal/Cervical swab
 Vaginal Examination
 Overall assessement
 Investigation protocols
 Principle of Management
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 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.
 Grading Management
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 Grade I:
 Drugs:
 Antibiotics

 Prophylactic Antigas gangrene serum

 8000 units and 3000 units of Antitetanus serum IM
 Analgesics & Sedatives
 Blood transfusion.
 Evacuation of uterus: Excess of bleeding is an
indication
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 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
 Grading Management
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 Grade II:
 Drugs:
 Antibiotics
 Prophylactic Antigas gangrene serum
 Analgesics & Sedatives
 Blood transfusion more needed than in Grade I.
 Clinical monitoring: Note pulse
 Respiration
 Temperature
 Urinary output
 Progress of pain, tenderness
 mass in lower abdomen
 CVP greater than 8 mm Hg
 Grading Management
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 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
 Grading Management
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 Grade III:
 Antibiotics as in Grade I & II.
 Clinical monitoring as in Grade II.
 Supportive therapy: Treat generalized peritonitis
 By gastric suction
 Intravenous crystalloids infusion

 Management of Endotoxic shock/ Renal Failure

 Features of Organ Dysfuction carefully guarded.
 May need Intensive Care Unit Management
 Active Surgery
 Features of Organ Dysfunction
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 Persistent hypotension (SBP < 90 mm Hg)

 PaO2 : <40 kPa Tissue perfusion

 Serum Lactate ≥ 4 mmol/L

 Oliguria
 Serum Creatinine > 44.2 umol/L
 Coagulation abnormalities (INR > 1.5)
 Thrombocytopenia
 Hyperbilirubinemia
 Indication for ICU Management
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CVS • Persistent Hypotension

• Persistent raised serum
lactate (≥ 4 mmol/L)
Respi • Pulmonary edema
• Mechanical Ventilation
• Airway protection
Renal • Renal Dialysis

Neurological • Impaired consciousness

Miscellaneous • Multiorgan failure

• Hypothermia
• Acidosis
 Active Surgery
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 Indications:
 Injury to uterus.
 Suspected injury to bowel.
 Presence of foreign body in abdomen
 Sonography/ Xray / felt through fornix on PV
 Unresponsive peritonitis s/o collection of pus.
 Septic shock/Oliguria not responding to
conservative treatment.
 Uterus too big to safely evacuated per
vaginum.
 References
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 Williams Textbook of Obstetrics, 24th edition

 DC Dutta’s Textbook of Obstetrics, 8th edition
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