SURGICAL MANAGEMENT OF SEPTIC ABORTION

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SURGICAL MANAGEMENT OF SEPTIC ABORTION

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SURGICAL MANAGEMENT OF SEPTIC ABORTION

  1. 1. SURGICAL MANAGEMENT OF SEPTIC ABORTION Dr. Jasmine Mehta M.D. Gynecologist, G. K. General hospital BHUJ
  2. 2. STATESTICS <ul><li>10% of all pregnancies end into abortion. </li></ul><ul><li>10% of all abortions admitted to hospital are septic. </li></ul><ul><li>% of maternal mortality is due to septic abortions. </li></ul>
  3. 3. Definition <ul><li>Any abortion associated with clinical evidences of infection of uterus and its contents is called as septic abortion. </li></ul><ul><li>Clinical evidences of infection are- </li></ul><ul><li>Fever 38 C or more for at least 24 hrs </li></ul><ul><li>Offensive or purulent vaginal discharge </li></ul><ul><li>Lower abdominal pain, tenderness or mass. </li></ul><ul><li>Tachycardia of more than 100 per min. </li></ul>
  4. 4. Clinical Grading of septic abortion <ul><li>Grade 1- Infection localized to uterus </li></ul><ul><li>Grade 2- infection beyond uterus to parametrium, tubes , ovaries or pelvic peritoneum </li></ul><ul><li>Grade 3- generalized peritonitis and or endotoxic shock or ARF </li></ul>
  5. 5. Indications of surgery <ul><li>Retained products </li></ul><ul><li>Injury to uterus </li></ul><ul><li>Suspected injury to gut </li></ul><ul><li>Presence of foreign body in abdomen as evidenced by x ray or PV </li></ul><ul><li>Unresponsive peritonitis or pelvic abscess </li></ul><ul><li>Septic shock or oliguria not responding to conservative treatment </li></ul>
  6. 6. Investigations before surgery <ul><li>Laboratory investigations: </li></ul><ul><li>Complete haemogram </li></ul><ul><li>Blood grouping and screening </li></ul><ul><li>Urine routine micro and culture sensitivity </li></ul><ul><li>UPT </li></ul><ul><li>Cervical or high vaginal swab culture </li></ul><ul><li>blood culture and sensitivity </li></ul><ul><li>RFT and LFT </li></ul><ul><li>Coagulation profile- BT ,CT, PT,APTT D-dimer </li></ul>
  7. 7. Investigations before surgery <ul><li>Imaging studies </li></ul><ul><li>X ray abdomen standing </li></ul><ul><li>USG abdomen and pelvis </li></ul>
  8. 8. Pre –operative management <ul><li>Resuscitation and correction of shock </li></ul><ul><li>Broad spectrum antibiotics </li></ul><ul><li>better to be guided by culture report later </li></ul><ul><li>3 rd gen cephalosporin+ metronidazole+aminoglycoside </li></ul><ul><li>Blood transfusion: keep at least 2 units of blood ready </li></ul><ul><li>supportive management with IV fluids, antipyretics and analgesics </li></ul><ul><li>Injection TT </li></ul><ul><li>Correction of coagulation profile if any </li></ul><ul><li>Prophylactic use of anti gas gangrene or anti tetanus serum </li></ul>
  9. 9. SURGERY <ul><li>Type of surgery needed depends on extent and type of pathology </li></ul><ul><li>E & C </li></ul><ul><li>Posterior colpotomy </li></ul><ul><li>Laparotomy- to drain pelvic abscess, to repair uterine perforation, to repair gut injury with or without performing colostomy </li></ul><ul><li>hysterectomy </li></ul>
  10. 10. Types of surgery required
  11. 11. Evacuation and curettage <ul><li>Give antibiotic coverage before 24 hrs of the procedure </li></ul><ul><li>If there is heavy bleeding, one may not wait for completion of 24 hrs of antibiotics </li></ul><ul><li>Inj. Prostodin 1 hr before the procedure </li></ul><ul><li>Procedure has to be carried out by senior surgeon-gentle but complete evacuation has to be done </li></ul><ul><li>Avoid perforation: it is likely as tissues are very friable </li></ul><ul><li>Send the obtained tissue for histopathology and culture </li></ul><ul><li>Complications- perforation ,bleeding </li></ul>
  12. 12. Posterior Colpotomy <ul><li>Indication: Pelvic abscess </li></ul><ul><li>Requirements for colpotomy drainage </li></ul><ul><li>the abscess must be </li></ul><ul><li>In midline </li></ul><ul><li>adherent to cul de sac peritoneum </li></ul><ul><li>cystic or fluctuant </li></ul><ul><li>Complications </li></ul><ul><li>False passage </li></ul><ul><li>Intra peritoneal rupture of abscess </li></ul><ul><li>bleeding </li></ul>
  13. 13. Method of posterior colpotomy <ul><li>Anesthesia, lithotomy position, catheterization </li></ul><ul><li>Examination under anesthesia to confirm area of maximum fluctuation </li></ul><ul><li>Cx grasped and pulled upward and forwards. </li></ul><ul><li>Colpopuncture with wide bore needle on near midline keeping direction of needle in axis of pelvis </li></ul><ul><li>Pus withdrawn and sent for culture </li></ul><ul><li>A transverse incicion of 2cm at the level of colpopuncture </li></ul>
  14. 14. Method of posterior colpotomy <ul><li>Blunt kelly’s forceps introduced in POD and opened to allow pus to drain </li></ul><ul><li>Septations in abscess cavity are broken with gloved index finger </li></ul><ul><li>Drain kept and sutured with vaginal vault </li></ul><ul><li>Drain should be removed after 48 hours to prevent pressure necrosis of ant rectal wall </li></ul><ul><li>Avoid extension of incision to laterally to prevent injury to ureter or uterine artery </li></ul>
  15. 15. LAPAROTOMY <ul><li>Indication </li></ul><ul><li>Injury to uterus, or gut </li></ul><ul><li>Presence of foreign body in abdomen </li></ul><ul><li>Unresponsive peritonitis or pelvic abscess </li></ul><ul><li>Method </li></ul><ul><li>Transverse Maylard incision is ideal </li></ul><ul><li>Pelvic adhesion released and bowel packed off </li></ul><ul><li>pus drained out and sent for culture </li></ul><ul><li>Foreign body removed </li></ul><ul><li>Uterus, adenexa and intestines are explored for injury or bleeding </li></ul><ul><li>Uterine perforation repaired in single layer </li></ul><ul><li>Intestinal perforation repaired in 2 layers </li></ul><ul><li>Povidone iodine wash given </li></ul><ul><li>Drain kept </li></ul><ul><li>Abdomen closed in layers </li></ul>
  16. 16. LAPAROTOMY IN CASE OF TUBOOVARIAN ABCCES <ul><li>Midline vertical or paramedian incision </li></ul><ul><li>Pus drained and sent for culture </li></ul><ul><li>Omentum and small bowel seperated from T-O mass by gentle blunt dissection with fingers </li></ul><ul><li>Separate ovary and tubes from uterus, sigmoid colon, and broad ligament </li></ul>
  17. 17. LAPAROTOMY IN CASE OF TUBOOVARIAN ABCCES <ul><li>Apply clamps </li></ul><ul><li>Clamp-1 Infundibulopelvic ligament </li></ul><ul><li>Clamp-2 Broad ligament below ovary </li></ul><ul><li>Clamp-3 Fallopian tube and ovarian tube and ovary removed, wash given , sdrain kept </li></ul><ul><li>Abdomen closed in layers </li></ul>
  18. 18. HYSTERECTOMY <ul><li>Indication </li></ul><ul><li>Irreparable injury to uterus bilateral tuboovarian abscess </li></ul><ul><li>Spreading gas gangrene infection in uterus </li></ul><ul><li>Method </li></ul><ul><li>Maylard or midline incision </li></ul><ul><li>Pus drained out </li></ul><ul><li>Separate T-O masses from bowel, back of uterus, POD and broad ligament by upward and lateral maneuvering </li></ul><ul><li>First round ligament identified and ligated </li></ul>
  19. 19. HYSTERECTOMY <ul><li>Ant fold of peritoneum opened </li></ul><ul><li>Infundibulopelvic ligament ligated </li></ul><ul><li>Due precaution for ureter </li></ul><ul><li>Subtotal hysterectomy may have to be done </li></ul><ul><li>Vaginal vault kept open for draiage </li></ul><ul><li>Abdomen closed in layers </li></ul>

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