This document presents a case study of a 27-year-old woman admitted with septic shock following an unsafe abortion attempt. She underwent an abortion procedure at a local hospital and developed severe abdominal pain, fever, and vomiting. She was referred to multiple hospitals and her condition deteriorated further, with symptoms of sepsis and multiple organ dysfunction. Upon admission, she was in septic shock. Laboratory findings showed signs of infection and organ failure. She underwent surgery which found pelvic abscesses. She received intensive care including ventilation, antibiotics, and organ support. Her condition gradually improved with treatment but she continued to have respiratory issues. The case demonstrates the dangers of unsafe abortion and importance of proper infection prevention and management of septic abortion and shock

1. SEPTIC ABORTION : WHERE
WE STAND (CASE
PRESENTATION)
Dr Subhrata Nanda

2.  Mrs S C, age 27yrs, from Puri admitted in
labour room at 1am on 5/5/17 during
emergency hours with complain of pain
abdomen, vomiting, loose motion, yellow
discolouration of body and eyes &
decreased urination with reddish
discolouration of urine since last 3 days

3.  She is G4 P3 L3 at 19 wks of gestation
went to a local hospital at Niali for MTP
and MTP was tried . After 24hrs on 3/5/17
pt developed severe abdominal pain which
subsided within 2hr without any
medication. Then pt was referred to
another hospital in Bhubaneswar where
evacuation was done at 10pm on 3/5/17.
There perforation was detected by the
surgeon and pt was put on conservative
management.

4.  On 4/5/17 pt developed pain & swelling of
abdomen, jaundice, oliguria. She was
referred to Hi-Tech medical college where
she was diagnosed as septic shock in low
condition. Due to unavailability of ICU, pt
was referred here.

5. PATIENT CONDITION ON
ADMISSION
 Pt was toxic, tachypnoeic, pale, icteric,
pulse 130/min feeble, BP 80/40
mmhg, RR 30/min
 On P/A it was tense, tender, guarding
+, rigidity +, bowel sounds sluggish
 On P/S vulval edema +, with muddy
discharge, foley’s catheter insitu with
50ml of haemorrhagic urine
 On P/V Ut 16wks, soft and tender

6.  Pt was shifted to ICU and pt condition
deteriorated (fall in SpO2 urine output
nil for 12hrs). USG done and the
diagnosis ?uterine perforation, pelvic
collection with B/L acute medical renal
disease and B/L moderate pleural
effusion. Decision for laparotomy was
done to rule out bowel perforation.
Laparotomy was done at 4pm on
5/5/17 in presence of surgeon.

7. Intra operative findings
 There was 200ml of yellowish dirty
collection. No bowel perforation
detected. There was a broad ligament
hematoma on right side of size 5X
4cm. Uterus contour was intact. B/L
tubes and ovaries healthy. Hematoma
was drained and peritoneal lavage
was done and intra peritoneal drain
was left. Pt shifted back to ICU

8. LAB FINDINGS ON ADMISSION
 Hb- 7.4 gm%
 PCV – 22%
 T wbc – 21000/ cc
 TPC- 70000/cc
 PT- 22.2(↑)
 aPTT- 95.9(↑)
 INR- 1.32
 Fibrinogen – 508
mg/dl
 Urea- 86mg/dl
 Creatinine- 2.3mg/dl
 Serum billirubin-
9.3mg/dl , D-
6.2mg/dl
 LFT- raised
 CBC notes- toxic
change +, shift to left
+
 Culture from urine,
blood and peritoneal
fluid shows no
growth. Tracheal
culture shows
Acenobacter

9. IMPRESSION
SEPTIC ABORTION WITH MODSODS

10. MANAGEMENT
 Pt was in ICU
 Pt was on mechanical ventilation,
crystalloids, Inotropes, BT, FFP, Platelet,
Dialysis and broad spectrum antibiotics
and other supportive measures.
 Then pt gradually improving and
intraperitoneal drain was removed on
15/5/17 and extubated on 16/5/17 and
due to shortness of breath on 17/5/17
she was on NIV.

11. CLINICAL FINDINGS ON
17/5/17
 Pt is conscious and oriented and
catheterized and on central venous line
 Dyspnoeic and on NIV
 Anaemic, no icterus, B/L pedal edema
 Vitals-pulse-134/min
BP-149/84mmHg without
ionotrops
RR-46/min
Temp-99.5F
 P/A-soft, parietal edema on flanks, BS
present, wound healthy

12. LAB FINDINGS
 CBC-Hb-6.5gm%,PCV-21%,TPC-2.04
lakhs with toxic changes
 S.cretinine-4.1 mg/dl and B.urea-129mg/dl
 LFT-normal
 Hypoproteinemia

13. CLINICAL FINDINGS ON
18.05.2017

14. DISCUSSION

15.  SEPTIC ABORTION-Any abortion associated with
clinical evidences of infection of the uterus and its
contents is called septic abortion.
 SEPTIC SHOCK/ENDOTOXIC SHOCK-Hypotension
(systolic BP <90mm Hg) is due to sepsis resulting in
derangements in cellular and organ system function.
Hypotension persists in spite of adequate fluid
resuscitation. Associated typically with septic abortion,
chorioamnitis, pyelonephritis and rarely postpartum
endometritis.

16. Clinical criteria of septic abortion
1. Rise of temperature of atleast
100.4ºF (38.4⁰C) for 24 hours or
more.
2. Offensive or purulent vaginal
discharge.
3. Other evidences of pelvic infection –
like lower abdominal pain and
tenderness.

17. Mode of infection
80% cases source of infection is
endogenous
Micro-organisms responsible are :
a) Anaerobic – Bacteroides group , Cl.
Welchii, Anaerobic streptococci
b) Aerobic – E.coli ,klebsiella, Staph ,
psuedomonas , MRSA

18. Pathogenesis

19. Pathology
80% - Infection localised to conceptus.
15% - Endomyometritis , spread to
parametrium , tube , ovaries
5% - Generalised peritonitis, endotoxic
shock

20. Clinical Features
 Sick , anxious
 Temperature > 38 C
 Chills and rigor
 Persistent tachycardia > 90 bpm
 Hypothermia(endotoxic shock) < 36 C
 Abdominal or chest pain
 Tachypnoea > 20 breaths per minute
 Impaired mental state
 Diarrhoea and/or vomiting
 Renal angle tenderness

21. Clinical Features
On Pelvic Examination :
 Offensive purulent vaginal discharge
 Uterine tenderness
 Boggy feel in POD (pelvic abscess)

22. CLINICAL GRADING OF SEPTIC
ABORTION
 Grade I – Infection localised to uterus
Grade II – Infection spread beyond
uterus to parametrium , tubes ,ovaries,
pelvic peritoneum
Grade III – Generalised peritonitis,
endotoxic shock, jaundice , acute
renal failure

23. Complications
IMMEDIATE :
 Hemorrhage
 Injury
 Generalised peritonitis
 Endotoxic shock
 ARF
 Lungs – Atelectasis, ARDS
 Thrombophlebitis

24. REMOTE :
 Chronic debility
 Chronic pelvic pain, LBA
 Dyspareunia
 Ectopic pregnancy
 Secondary infertility
 Depression

25. PRINCIPLE OF MANAGEMENT OF
SEPTIC SHOCK
 Appropriate supportive care
 Correction of hemodynamics
 Broad spectrum antibiotics
 Correction of acidosis
 Remove the source of sepsis

26. INDICATIONS OF SURGERY
 Injury to uterus
 Suspected bowel injury
 Presence of FB in abdomen
 Unresponsive peritonitis suggestive of
collection of pus
 Septic shock not responding to
conservative t/t
 Uterus is too big to be safely
evacuated vaginally

27. PREVENTION
 Strengthening family planning
practices
 Rigid enforcement of legalized
abortion in practice and to curb the
prevalence of unsafe abortion
 Proper antiseptic and aseptic
measures

28. KIND REQUEST ON BEHALF
OF SOCIETY
THINK TWICE BEFORE SAYING
NO
BECAUSE
A NO TODAY MAY FORCE YOU
TO
THINK EVERYDAY

29. 29