Management of Septic Abortion and Complications

MANAGEMENT OF
SEPTIC ABORTION
AND COMPLICATIONS
BY
DR. DENNIS ALLAGOA

CLINICAL
PRESENTATION
 HISTORY:
Hx. of an abortion may or may not be

volunteered
There is usually high grade fever
Generalized, Suprapubic, lower abdominal or
low back pain
Offensive vaginal discharge
EXAMINATION:
General-Pale, febrile, jaundiced, furred tongue,
offensive CVS-tachycardia and
hypotension
EXAMINATION Continued
 V/E: There may or may not be bruises on
vulva
Vagina is usually hot
Cervical Os may be open or closed
Uterus and adnaexae are usually
tender Pouch of Douglas
may be full and tender Cervical
motion tenderness is usually positive
Gloved examining fingers are
usually stained with offensive
bloody vaginal discharge
INVESTIGATIONS
 Full blood count, Hb genotype
 Platelet count and clotting time
 Blood grouping and cross-matching, Rh. Status
 Urinalysis + urine M/C/S
 Serum E/U/Cr
 Abdomino-pelvic USS;
Retained products of conception, abdomino-
pelvic abscesses, peritonitis (dilated bowel
loops), gas in the pelvis and fluid in the pouch
of Douglas etc.
 Plain erect abdominal X ray;
TREATMENT
 Serious gynaecologic emergency that requires
the involvement of senior members of the team
as early as possible.
 Adequate resuscitation is of vital importance
Crystalloids or colloids
Blood transfusion as necessary
Strict input/output chart
Antibiotics-Triple Regimen;
Intraveinous Ampicillin 1-2gm 6hrly for 24- 48hrs
Metronidazole 500mg 8hrly for 24-
48hrs
TREATMENT Continued
 Other useful antibiotics;
Cephalosporins-I.V. cefuroxime 750-1500mg 6-8 hourly
for 24-72 hrs, Ofloxacin, ciprofloxacin 400mg daily
 Evacuate the uterus after 24hrs of commencement of
antibiotics.
Switch over to oral antibiotics when appropriate as
determined by culture and sensitivity results.
ERPC should be done under general anaesthesia and
extreme cautioned should be taken not to perforate the
uterus if it has not been perforated already.
 Analgesia;
I.M Pethidine 100mg 4-6 hrly with I.M promethazine 25mg
8-12hrly 24-48hrs
 Tetanus prophylaxis;
Tetanus toxoid 0.5mg stat, Human Immuno Tetanus
Globulin 250-500 I.U. Stat
Management of
complications
 SEPTIC SHOCK
 _Caused by release of toxins by organisms
such as E.Coli, Klebsiella, Proteus
,Bacteriods etc
 -affects small vessels- cvs collapse.
 Clinical features
 Warm extremities.
 Hypotension-in the face of adequate fluid
replacement.
 Other evidence of sepsis.
 Sensorial imparment or coma
Treatment of septic
 Treatment shock
 Adequate infusion of crystalloids, colloids, blood
transfusion
 Refractory shock
-+vasopressors –Dopamine (renal dose)-

>6g/kg/hr
.HA-1A- Human monoclonal IgM antibodies
(centroxin)-100mg in 3.5g of Albumin
.Oxygen by face mask
.Monitoring of vital signs.
.Severe cases
-Endotrachael intubation/O2
-Respirator care
-ECG monitoring
-Pulse oximeter
-CVP monitoring
Abscesses & intestinal
injuries
Massive pelvic and abdominal
abscesses -pouch of Douglas,
paracolic gutters, general abdomen
Clinical features
-unrelenting fever, abdominal
distensions, absent or reduced bowel
sounds
Investigations
FBC, U/S scan, Erect plain abdominal X
ray
Mgt of Abscesses &
intestinal
 Co-management with the injuries
surgeons
 Adequate patient preparation before surgery
 The earlier the surgery, the better the prognosis
 Time spent on resuscitation is time well spent
- antibiotics, laparotomy –midline incision
- N/B No place for culdotomy
- -bowel resection and anastomosis, colostomy
-Drainage of abscesses
-irrigation of abdomen with normal saline
-Fascia closed with non absorbable sutures
-Massive Antibiotics
Haemorrhage/ DIC
 -inappropriate activation of the coagulation and
fibrinolytic system
 Causes
-septic abortion
-septicaemia
-massive blood transfusion
-saline induced abortion
Mx
Release of tissue thromboplastins and bacteria
endotoxins
Clinical features
Generalized bleeding, localized
purpura, petechia and
thromboembolic phenomenon, fever,
hypotension, proteinuria, frank
Mgt. Of Haemorrhage &
Investigations DIC
-Low platelets <100,000/ml
-Increased prothrombin time
-low fibrinogen <150mg/dl
-clotting time elevated
-bleeding time elevated
-fibrin degradation products elevated
Treatment
-Correction of underlying dx
-supportive treament
-correction of shock, acidiosis
-cardiopulmonary support
-fresh whole blood transfusion –massive haemorrhage
-platelet transfusion-platelet count < 50,000/ml
-subcutanous low dose heparin-intravascular clotting process
-contraindicated in fulminant D.I.C. and liver failure.
Prognosis
Good when treatment is started early
 If after uterine evacuation, haemorrhage is refractory( after
correcting DIC) then exploratory laparotomy is indicated-
ACUTE RENAL FAILURE
 Urinary output < 30mls per hour despite
adequate hydration and blood transfusion
 Deranged electrolyte, urea and creatinine
 When diagnosis is made,
 -refer to renal unit as early as possible.
 MGT OF ACUTE RENAL FAILURE
 Initial treatment:
Adequate hydration; fluid challenge with 200-250
mls of mannitol or I.V. frusemide 100-200mg.
Restrict fluid, institute renal failure regimen, high
CHO, low protein ,low potassium.
 Dialysis:
Haemodialysis
Peritoneal dialysis
PREVENTION
 Preventable cause of maternal
mortality and morbidity
 This involves:
- prevention of unwanted
pregnancies
- increasing access to safe abortion
practices
- effective management of abortion
complications through post abortal
care
Prevention of Unsafe
Abortion
 Preventable cause of maternal
mortality and morbidity
 This involves:
- prevention of unwanted
pregnancies
- increasing access to safe abortion
practices
- effective management of abortion
complications through post abortal
care
Levels of prevention
Primary
-provision of reproductive health
information and choices
-prevention of unplanned and unwanted
pregnancies
-provision of quality sexuality education to
all ages.
-Provision of sustainable contraceptive
delivery service.
- National policies on adolescent
reproductive health should be formulated
 Secondary
-programmes /activities aimed at
providing information and counseling to
women experiencing unwanted
pregnancy
N/B: Not available b/c of restrictive laws
Tertiary care
-Provision of services for treatment of
complications of unsafe abortion in
10,20 and 30 health facilities.
POST ABORTAL CARE
 -Empathetic & compassionate
 -Pre-procedure counselling of women
 Quality management with MVA
 Post procedure counselling to encourage
use of contraceptives to prevent repeat
abortions including effective linkages to
family planning services.
 Most of the reduction in abortion related
morbidity and mortality that has occurred
in Africa in the last couple of years an be
attributed to the introduction of post
abortion care services.
 The EXPANDED CONCEPT OF PAC is the
training of service providers especially
THANK YOU
FOR LISTENING

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MANAGEMENT OF

DR. DENNIS ALLAGOA

Hx. of an abortion may or may not be

-+vasopressors –Dopamine (renal dose)-

 Time spent on resuscitation is time well spent

- antibiotics, laparotomy –midline incision

- N/B No place for culdotomy

- -bowel resection and anastomosis, colostomy

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