1. SEPTIC
Anish Dhakal
(Aryan)

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
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3. Two types
 Spontaneous
 Threatened
 Inevitable
 Complete
 Incomplete
 Missed
 Septic- less
common
 Induced
 Legal
 Illegal (unsafe)
 Septic-common
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4. 4

5. 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 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
5

6. Incidence
 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
6

7. Association of sepsis in illegally
induced abortions
 Proper antiseptic and asepsis are not taken
 Incomplete evacuation
 Inadvertent injury to the genital organs and
adjacent structures, particularly the bowels
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8. Mode of infection
 Microorganism involved are normal vaginal
floraAnaerobes Aerobes
Bacteroides group
(fragilis)
Escherichia coli ,
Klebsiella
Anaerobic Streptococci Staphylococcus,
methicillin resistant
staphylococcus aureus
(MRSA)
Clostridium welchii Pseudomonas
Tetanus bacillus Group A beta Hemolytic
Streptococcus
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9. 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
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10. Clinical Features
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
10

11.  Pelvic examination
 Offensive purulent vaginal discharge
 Uterine tenderness
 Boggy feel in Pouch of Douglas (Pelvic Abscess)
11

12. Clinical grading
 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
12

13. Investigations
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
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14. Special Investigations
 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)
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15. 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
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16.  Endotoxic shock—mostly due to E. coli or Cl.
welchii infection
 Acute renal failure—patchy cortical necrosis
or acute tubular necrosis Cl. Welchii
 Thrombophlebitis
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17. Remote
 The remote complications include
 Chronic debility
 Chronic pelvic pain and backache
 Dyspareunia
 Ectopic pregnancy
 Secondary infertility due to tubal blockage and
 Emotional depression
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18. Prevention
 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
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19. Management
 General Management
 Grading Management
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20. General Management
 Hospitalization
 Vaginal/Cervical swab
 Vaginal Examination
 Overall assessement
 Investigation protocols
20

21. 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.
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22. 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: Excess of bleeding is an
indication
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23.  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
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24. Grading Management
 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
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25. 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
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26. 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 infusion
 Management of Endotoxic shock/ Renal Failure
 Features of Organ Dysfuction carefully guarded.
 May need Intensive Care Unit Management
 Active Surgery
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27. Tissue perfusion
Features of Organ Dysfunction
 Persistent hypotension (SBP < 90 mm Hg)
 PaO2 : <40 kPa
 Serum Lactate ≥ 4 mmol/L
 Oliguria
 Serum Creatinine > 44.2 umol/L
 Coagulation abnormalities (INR > 1.5)
 Thrombocytopenia
 Hyperbilirubinemia
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28. 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
Indication for ICU Management
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29. Active Surgery
 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.
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30. References
 Williams Textbook of Obstetrics, 24th edition
 DC Dutta’s Textbook of Obstetrics, 8th edition
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