Management of miscarriage

and sepsis

ESMOE
 Aims

 To recognise a miscarriage (safe/unsafe/septic)

 To learn how to perform a manual vacuum

aspiration (MVA)

 To learn how to recognise and manage sepsis

 To achieve competence in those skills

 Clinical types of miscarriage
Spontaneous
Threatened
Inevitable
Incomplete
Missed
Complete

Induced
Termination of pregnancy
Complicated miscarriage
Uncomplicated miscarriage

MVA at CHC/Level 1 Hosp

P < 90 bpm, RR < 20 bpm, T < 37.2 oC,

HB >10g/dl
Uterus <12 weeks in size
POC not foul smelling
No clinical signs of infection
No suspicious findings on examination
Complicated miscarriage

Anything else!

Management at:
Level 1 with theatre facilities
(provided no organ system
dysfunction)

Level 2 or 3
 A word on ectopic pregnancy
Do a pregnancy test on all patients of
reproductive age!

If positive locate the site of the pregnancy

If intra-uterine (IU) continue

If not obvious perform a quantitative ßHCG

 ßHCG interpretation
< 1500iu – no IU preg on sonar
>1500iu – IU preg will be seen with TVS
>5000iu – IU preg will be seen on abd sonar

If the uterus is empty → ECTOPIC

A high index of suspicion is required!
If in doubt → REFER
 Performing an MVA
• See DVD/CD
Skills station: Performing an MVA
 The importance of recognising
sepsis

Most cases of severe morbidity and mortality

occur because at initial assessment the
severity of illness is not appreciated

Never underestimate the risks associated

with severe sepsis
 Recognition

Systemic inflammatory response syndrome

(SIRS)

SIRS is associated with a significant ↑in M&M

These patients must be admitted

 What is SIRS?

A clinical response from a non-specific insult

With ≥ 2 of the following:
Temperature >38°C or <36°C
Heart rate > 90/min
Respiratory rate > 20/min or PaCO2
<4.3kPa
White cell count > 12 x 109/l or < 4 x
109/l
 Importance of SIRS

Sepsis definition:

SIRS due to presumed/confirmed

infectious process

It is the initial systemic response to a local

insult
 Severe sepsis

Sepsis with associated organ dysfunction

Cardiovascular [SBP< 90mmHg]
Respiratory [RR > 26/min or
SaO2 < 90%]
Renal [oliguria <30ml/hr for 2h
despite fluids]
Tissue hypoperfusion
Altered mental status
Decreased capillary refill or mottling
Hyperlactemia, Hyperbilirubinemia
 Septic shock
Sepsis with hypotension

(despite adequate fluid resuscitation)

combined with hypoperfusion abnormalities

MOD
Mulitple organ dysfunction
 Principles of management
 Asses the need for resuscitatsion - Call-a-CAB
 Recognize severe sepsis and septic shock
 Fluid resuscitation ➙ normotensive
 Broad spectrum IV antibiotics within 1st hour
 Obtain relevant cultures (i.e. blood, urine,
sputum)
 Make clinical diagnosis ➙ secondary survey
 Source identification and site control -
consider surgical management if appropriate
 Goal directed resuscitation

GOALS

- MAP > 65 mm Hg or SBP > 100 mm Hg

- CVP > 8 mm Hg
- SaO2> 90%
- RR < 30 bpm
- Hct > 30% Hb > 10 g/dl
Secondary survey

 History – if possible

 Examination
– Organ system evaluation…
 Organ system evaluation 1
• Big 5
– CNS AVPU
– CVS Tachycardia; shock
– Resp Tachypnoea, SaO2<90%
– Liver & GIT Abnormal liver enzymes,
glucose, bowel sounds, acute abd
– Renal Decreased urine output, ⇡ urea and
creatinine
 Organ system evaluation 2
• Forgotten 4
– Haematological Hb, Plt, WCC, INR, PTT, Fibrinogen
– Immunological HIV status, temperature
– Endocrine Glucose reduced, TSH
– Musculo-sketetal DVT

• Core 1
– Genital system
– Uterine size, abdominal tenderness, cervix open, foul
smelling discharge
 Common sources of sepsis…
Resp:
CNS: Atelectasis
Meningitis Aspiration
Encephalitis Pneumonia

CVS: Breasts:
Endocarditis Mastitis
Breast abscess

Urinary Tract: Genital System:

Cystitis Septic miscarriage
Pyelonephritis Endometritis
Septic episiotomy
GIT: Pelvic vein thrombosis
Bowel Injury PID
Appendicitis
Gastroenteritis Hematological:
Wound Infection Thrombophlebitis
Hepatitis Deep vein thrombosis
DIC
 Recognizing a complicated
miscarriage
 Fever: temperature > 38 oC
 Warm extremities
 Fast breathing
 Increased maternal heart rate
 Altered mental state
 Low BP
 Septic shock
 Tender lower abdomen
 Cervix open with a foul smelling discharge
 Signs of cervical trauma
Management: septic miscarriage

“Call a CAB”
Assess need for immediate resuscitation
Stabilise (airway, IV, intake/output, blood
investigations, antibiotics)
Further history
Secondary survey
Secondary survey

The Big 5

The Forgotten 4

Core 1
 Parenteral antibiotics

Start antibiotic therapy as part of initial

resuscitation

Patient should not go to theatre until 2

hours after starting antibiotics to ensure
adequate tissue levels
 What antibiotics?

 Combination of
 Cephalosporins (3rd generation IV)
If not available IV Clindamycin or
Ampicillin
 Gentamicin 5 mg / kg im every 24
hours plus
 Metronidazole 500 mg iv 8 hourly or
orally 400mg tds
 Indications for hysterectomy

Two organ systems dysfunction

One organ system dysfunction with a uterus

larger than 16 weeks after evacuation
 RECAP

Recognition of complicated and

uncomplicated miscarriage
Principles of management
How to perform a MVA
Signs and grading of sepsis
Early parenteral antibiotics
Goal directed resuscitation
Skills station : Septic miscarriage