2. CASE
PATIENT PARTICULARS:
oName: Lamin Tamang
oAge: 36 years/ Fe
oAdress: Kavre
oAdmitted to Obs& Gynae on 21st Mangsir 2072 at 5:30 pm from Emergency
department
Chief complaint:
Amenorrhea for 2 months followed by PV bleeding for 11 days after self
induced medical abortion at 7wk and 2 days of gestation.
Lower abdominal pain for 11 days
Fever for 1 day
3. History of presenting illness
• Cessation of menstruation for 2 months
• History of self induced medical abortion at 7wk and 2 days of gestation.
• PV bleeding following self induced medical abortion for 11 days, uses 2- 3
soaked pads per day for it with presence of clots
• Lower abdominal pain for 11 days , mild pain which become severe in last 3
days, radiating to back, not known aggravating and relieving factor.
• Fever for 1day with no chills and rigor, max temp not recorded.
• No h/o burning micturition , and increased frequency
• No h/o SOB , palpitation, headache , dizziness and LOC.
4. Obs history: she is P2 A1 L2,
1St child : Fe, 18 yr. Term,ND at home, no complications
2nd child: M , 15 year , Term, ND at home , no complications
Contraceptive history: No h/o use of contraceptive measures
Menstrual History : K- 15yr,
duration of blood flow for7-8days ,
duration of cycle 28-30 days,regular,
clots (+), dysmenorrhea(+)
Inter menstrual bleeding- Absent
Personal history: Non smoker, and does not consume alcohol. No
known allergies to any food and drugs, non vegetarian
5. Family History: No h/o DM, TB , HTN, Bleeding disorder, and
female genital tract malignancies in family members.
Past history: No h/o DM, TB , HTN
No h/o surgical intervention done in past.
8. Systemic examination:
Chest : B/L equal air entry ,NVBS with no added sounds.
CVS : S1 + S2 + M0
PA : soft, supra pubic tenderness( + ), no organomegaly
9. Gynae/ Obs Examination
• PS:
• Cervix : Normal
• OS : Open
• Mild bleeding (+)
• PV :
Vulva and vagina : normal
Uterus 6 wk size Anteverted and tender
Fornices : firm and Tender.
10. Management:
Patient was immediately admitted in Gynae and Obs ward ,
And following investigations were sent
•Investigations:
UPT: positive
Hb: 12.1gm/dl
TC : 14,100 /cmm
• N- 85 %, L-14%, E-1%,
Platelet : 2,67,000/cmm
Blood group: B positive
RFT: serum urea: 20 mg/dl (N) , serum creatinine: 0.7mg /dl(N)
Na/k= 143/4.1
11. LFT : serum bilirubin:
Bilirubin total : 0.8 mg/dl (N)
Bilirubin direct: 0.2 mg/dl (N)
SGOT : 54 IU/L (raised),
SGPT : 37 IU/l (N)
Total protein: 6 gm /dl(N)
Serum albumin: 4.4 gm/dl(N)
Urine RME: WNL
High vaginal swab: normal vaginal flora seen
12. USG finding:
Bulky uterus with mixed echoic lesion in endometrial cavity ? Product
of conception( 2.3 * 2.6 cm )
Uterus Enlarged (10.4* 5.9*5.5 cm)
Outline regular
13. Treatment received on 1st day of admission
• IV line was opened and hydration was maintained with Inj. RL 2 pint
IV over 24 hrs
• Foley’s catheterization was done.
• Inj. Ceftriaxone 1 gram IV BD
• Inj. Metronidazole 500 mg IV TDS
• Inj. ranitidine 150mg IV TDS
14. On the second day of admission(2072/3/22)
With aseptic precaution MVA was done
• Findings: around 30 ml of RPOL and clot removed.
• No active bleeding at the end of procedure.
• And specimen send for HPE.
• Post procedure Vital:
• BP : 100 / 90 mm Hg , Pulse : 90 bpm
Oral antibiotic:
Tab Cefixime 200mg PO BD.
Tab Metronidazole 400 mg PO TDS.
Tab Ranitidine 150mg PO BD.
Tab Flexon 1 tab PO TDS.
15. • On day 3rd patient vitals were stable and Patient was discharged
after insestion of Jadelle with following medications:
• Tab Cefixime 200 mg PO BD 5 days
• Tab Metronidazole 400 mg PO TDS 5 days
• Tab Aciloc 150 mg PO BD 5 days
• Tab Flexon 1 tab PO for 2 days then SOS
17. • Abortion: It is the expulsion or extraction from its mother of an
embryo or fetus weighing 500 gm or less when it is not capable of
independent survival (WHO).
• The 500gm of fetal development is attained approximately at 22
weeks of gestation.
20. SEPTIC ABORTION
• Any abortion associated with clinical evidences of
infection of uterus and its contents is called as
septic abortion.
21. EPIDEMIOLOGY
• Septic abortion remains a primary cause of maternal mortality in the
developing world, mostly as a result of illegal abortions
• 21.6 million women experience an unsafe abortion worldwide each
year; 18.5 million of these occur in developing countries
• 47 000 women die from complications of unsafe abortion each year.
• Deaths due to unsafe abortion remain close to 13% of all maternal
deaths.
22. Data collected in our KIST Hospital from
Baisakh to mangsir
MVA:19
MA:73
MI:12
D&E:11
Self induced
abortion: 8
Septic
abortion : 3
Total
abortion: 126
Self induced abortion: 8.73%
Among self induced abortion, Septic
abortion is 27%
23. ETIOPATHOGENESIS
Begins as endometritis and involves
the endometrium.
If not treated, the infection may
spread further into the myometrium
and parametrium.
Parametritis may progress into
peritonitis.
Bacterimia and septic shock
Retained Product of
Conception
• From incomplete spontaneous
abortion or therapeutic
abortion
Introduction of Infection
into the Uterus
• Pathogens that caused septic
abortion usually mixed and
derived from vaginal flora and
sexually transmitted bacteria
24. Clinical evidences of infection are-
1. History of pregnancy or Abortion.
2.Fever 38 C or more for at least 24 hrs
3. Offensive or purulent vaginal discharge
4.Lower abdominal pain, tenderness or
mass.
5. Tachycardia of more than 100 per min.
25. On Examination :
General condition: ill looking or toxic
patient may be pallor or dehydrated.
vitals:
pulse : may be raised, bounding or low volume pulse,
BP: may be low
Temperature: may be raised or afebrile
NOTE:A rising pulse rate of 100–120/min or more is a significant finding than even
pyrexia. It indicates spread of infection beyond uterus!
26. Per Abdomen:
1. abdominal tenderness, guarding, rigidity
2. Internal examination reveals:
• offensive purulent vaginal discharge
• tender uterus usually with patulous os or a boggy feel
• Soft cervix with open internal os
27. 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.
Grade-I is the commonest and is usually associated with spontaneous
abortion
Grade- III is almost always associated with illegal induced
29. ROUTINE INVESTIGATIONS
Haematology:
• Hb : may be low
• Platelets: may be low
• TLC: raised
• DLC: Neutrophil raised
• Blood C/S.
• Blood grouping and cross matching
Urine analysis:
• UPT
• RME and C/S
High vaginal swab is taken prior to internal examination for-
1. culture in aerobic and anaerobic media to find out the dominant micro organisms
2. sensitivity of the micro organisms to antibiotics
3. smear for Gram stain
30. SPECIAL INVESTIGATIONS
• Ultrasonography pelvis and abdomen to detect intrauterine retained
products of conception , foreign body- intrauterine or intra-
abdominal , free fluid in the peritoneal cavity or in the pouch of
Douglas
• Fibrinogen level, fibrin degradation product and d-dimer to rule out
DIC
• RFT
• Plain chest X-ray to rule out atelectasis and abdomen to rule out
bowel injury or foreign body.
31. PRINCIPLES OF MANAGEMENT
• To control sepsis
• To remove the source of infection
• To give supportive therapy to bring back the normal homeostatic and
cellular metabolism.
• To assess the response of treatment
33. Grade 1
For Gram Positive aerobes-
Aqueous penicillin G 5 million I.V. every 6 hour
Ampicillin 0.5-1 Gm. I.V. every 6 hour
For Gram Negative aerobes-
Gentamicin 1.5mg/kg I.V. every 8 hour or
Ceftriaxone 1G , I.V. every 12 hour
34. • For Anaerobes- Metronidazole 500mg I.V. every 8 hrs , or
clindamycin 600mg I.V. every 6 hrs
Antibiotic regimens have to be modified according to the
culture and sensitivity report as obtained later on.
• Prophylactic Anti gas - gangrene serum of 8000 units and
3000 units of Antitetanus serum i.m. are given if there is a
history of interference.
• Analgesic and sedatives , as required.
35. • Blood Transfusion is given to improve anaemia.
• Evacuation of the uterus: As abortion is often
incomplete, evacuation should be performed at a
convenient time within 24 hrs following antibiotic
therapy . Excessive bleeding is, of course, an urgent
indication for evacuation . Early emptying not only
minimises the risk of haemorrhage but also removes
the nidus of infection. The procedure should be gentle
to avoid injury to the uterus.
36. Grade 2
• Antibiotic anti gas gangrene , anti tetanus serum and analgesics as
grade 1
• Surgery:
• Evacuation of the uterus- Should be withheld for at least 48hrs when
the infection is controlled and is localised , the only exception being
excessive bleeding.
• Posterior colpotomy- When the infection is localised in the pouch of
Douglas pelvic abscess is formed. It is evidenced by spiky rise of
temperature , rectal tenesmus(frequent loose stool mixed with
mucus) and boggy mass felt through the posterior fornix. Posterior
colpotomy and drainage of the pus relieve the symptoms and improve
the general outlook of the patient.
37. Grade 3
• Supportive therapy is directed to generalised peritonitis by gastric
suction and i.v. saline infusion.
• Management for endotoxic shock or renal failure , if present, is to be
conducted. Patient may need intensive care unit management.
38. Complications:
Immediate:
• Hemorrhage
• Injury may to uterus & adjacent structures
• Spread of infection leads to:
• Generalized peritonitis
• Endotoxic shock—mostly due to E. Coli
• DIC
• Acute renal failure
• Thrombophlebitis.
• All these lead to increased maternal deaths
Remote complication:
• Secondary Infertility
• Chronic pelvic pain
• Ectopic pregnancy
39. Incidence of septic abortion: 2014 in Srilanka
(Ragama city)
• A 39 year old lady living together with her male partner and pregnancy was
confirmed. She went to a “place for abortion”. At that place a tube was
inserted into her vagina and suction was done by the “abortionist”.He did
some procedure for evacuation. After coming home she had severe vaginal
bleeding and chills. Second day she was admitted to the hospital with fever,
abdominal pain, heavy vaginal bleeding and low blood pressure. Third day
evacuation of retain products of conception and laparotomy was planned
to renowned hospital of that state , suspecting bowel perforation but her
hemodynamic stability was completely compromised, leading to death.
• Finally the postmortem of dead body was done which revealed the
turpentine oil in uterus ,uterine perforation with haemopertonium.
