Septic Abortion and Puerperal Infection

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Septic Abortion and Puerperal Infection
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Septic Abortion Introduction

• History
• Physical Examination
• Problem list
• Differential diagnosis
• Investigation
• Management
• Septic Abortion

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...History...
4
History (14 ?.?. 44) ????????????????? ????
18 ?? ???????????? ????????? ???????? G1 P0 LMP
23 ?.?. 44 GA 83 wk, no ANC ??????????????????
????? CC ????????????????????? 1 ??? PI 3 d
PTA???????????????????????????????????????
??? ????????????????????????????
??????????????? ?????????? ??????????????
capsule ????-??? ??? ?????????????
5
History PI 2 d PTA ?????????
???????????????????? ????????? ????????????????
4 hr PTA ????????????????????????
????????? ??? ????????????? pad
???????????????????? ?????????????? ??????
???????????? ??? ??????????? PH - No
underlying disease -????????
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Physical Examination
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Physical Examination A woman looked acutely
ill Vital signs BT 39.0 oc BP 90/60
mmHg PR 90/min. RR 20/min. HEENT not pale,
no jaundice Heart normal S1 S2 , no
murmur Lungs clear Abdomen liver and
spleen not palpable Tender with rebound
tenderness at suprapubic region, no mass,
active bowel sound
8
Physical Examination PV NIUB - normal Vag. -
bloody discharge, no foul smell Cx - os closed,
excitation negative Ut. - enlarged, A/V,
gestational 8 wk size, tender Adnx. - no mass
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Problem list?
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Problem list

• Bleeding per vagina after criminal abortion
• lower abdominal pain with rebound tenderness
• Fever
• Uterus 8 wk. size, tender

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Differential diagnosis?
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Differential diagnosis

• Gynaecologic - Septic abortion - Ectopic
  pregnancy - PID - UTI in pregnancy

• Surgical - Acute appendicitis

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Investigation?
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Investigation

• CBC
• Beta - hCG
• Electrolyte, glucose, BUN, creatinine
• Matching and grouping
• Endocervical swab for cultures (eg, aerobic,
  anaerobic) and gram stain
• Ultrasound
• Abdominal x-ray

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Investigation (14 ?.?. 44) 1. Complete Blood
Count RBC 4.35x106 /ml HGB 11.6 g/dl HCT
34.5 MCV 79 fl MCH 26.7 pg MCHC 33.7
g/dl RDW 14.0 WBC 21.7x103 /ml (H) NE 89.4
(H) LY 6.4 (L) MO 3.2 EO 0.5 (L) BA
0.2 LUC 0.3 PLT 292,000 /ml
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Investigation 2. Bacteriology Cervical
swab - no growth Haemoculture - no growth 3.
Blood Chemistry BUN 6.0 mg/dl Creatinine
0.6 mg/dl
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Investigation 4. Urinalysis Appearanc
e - yellow Sp.gr. - 1.010 pH 7.0 Protein
negative, Glucose negative, Ketones negative,
Bile/Urobilinogen negative, no RBC, WBC 0-1, no
bacteria 5. Serology and immunology anti HIV
negative
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Management?
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Management

• Monitor vital signs - BT, BP, PR, RR
• Administer IV fluids through a large-bore
  angiocatheter to maintain blood pressure and
  urine output
• For patients who are unstable, administer oxygen
  and insert a Foley catheter
• Early antibiotic treatment may be guided by gram
  stain, but broad-spectrum coverage is recommended
  
• In patients with Rh negative, Rh immunoglobulin
  should be given

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Management

• Perform evacuation of retained tissues from the
  uterine cavity, preferably by dilation and
  curettage (DC). If DC is not immediately
  available, high doses of oxytocin can be used
• Laparotomy may be needed if the above measures
  elicit no response
• A hysterectomy may be necessary in cases of
  uterine perforation, bowel injury, clostridial
  myometritis, and pelvic abscess
• Management of septic shock, if present

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Management (14 ?.?. 44) 1. 5 DN/2 1000 ml x
1 i.v. drip 120cc/hr. 2. Broad-spectrum
antibiotics - Ampicillin 1 gm i.v. q 6
hr - Gentamicin 240 mg 5 DW 100 cc
i.v. drip in 1 hr, OD - Metronidazole 500 mg
i.v.q 8 hr 3. Paracetamol (500) 2 tab prn for
fever q 6 hr 4. TT 0.5 ml i.m. stat, TAT 3000
unit i.m. after skin test negative
5. Dilation and Curettage , after at least
4 hours of broad-spectrum antibiotics
administration
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Operative note (14 ?.?. 44) Preoperative
diagnosis septic criminal abortion Operative
diagnosis septic criminal abortion Operation
Dilation and Curettage Anaesthesia
paracervical nerve block Position
lithotomy Operative finding uterine sound
10 cm A/V, conceptus 2 gm, blood loss 20
cc Operative procedure Dilation and Curettage
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Pathology report (16 ?.?. 44) GROSS specimen,
received in formalin, labeled with the patients
name and conceptive product is irregular brown
tissue weighing 2 g Block A conceptive
product DIAGNOSIS Endometrium
Hypersecretory endometrium with acute
inflammation NOTE No chorionic villi seen
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????... ?????... ???? ??...!!!
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Clinical improvement after DC

• Day1 ???????????????? ?????????????
  ?????????????? BT 37.8 oc, BP 90/60 mmHg, PR
  70/min., RR 20/min. Abdomen - soft, mild tender
  at suprapubic region Management Paracetamol,
  continue antibiotics i.v., methergin i.m.

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Clinical improvement after DC Day 1
Oc Admission
Day 1 Day 2
Day 3 Day 4
40
39 38
37 36
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Admission 39 oc
Progress 37.8 oc
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Clinical improvement after DC

• Day2 ??????? ????????????? BT 37.0 oc,
  BP110/60 mmHg, PR 88/min., RR 20/min. Abdomen -
  no tenderness Management Antibiotics i.v.
  ????? 48 ???????????????? ???? ??????????? oral
  form

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Clinical improvement after DC Day 2
Oc Admission
Day 1 Day 2
Day 3 Day 4
40
39 38
37 36
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Progress 37.0 oc
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Clinical improvement after DC

• Day3 BT 36.8 oc, PR 84/min. Management
  Augmentin p.o. ??? DMPA i.m.

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Clinical improvement after DC Day 3
Oc Admission
Day 1 Day 2
Day 3 Day 4
40
39 38
37 36
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Progress 36.8 oc
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Clinical improvement after DC

• Day4 discharge Medications on discharge
  FeSO4, Paracetamol, Augmentin(625mg) 1x3 pc

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Clinical improvement after DC Day 4
Oc Admission
Day 1 Day 2
Day 3 Day 4
40
39 38
37 36
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Discharge 36.5 oc
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Septic Abortion

• Definition ??????????????????????????????????????
  ?????????????-????????? ??????????????? 38
  ??????????????????????????? 2 ???
  ?????????????????????????? ???? ??????? 38.9
  ?????????????????????????????????
• Diagnosis - History - Symptoms and
  Signs - Investigation
• Treatment - Supportive - Specific

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Puerperal InfectionIntroduction

• History
• Physical Examination
• Labour record
• Progress note
• Differential diagnosis
• Investigation
• Puerperal Infection
• Questions

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...History...
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History ????????????????? ???? 32 ?? ????????????
????????? ??????????? 1st admission (27 ?.?.
43) ??????????????????????? G2P1 last 4
years (41 wk, NL, ?????????), GA 42 wk. By
date LMP 5 ?.?. 42 EDC 12 ?.?. 43
ANC x 6 ????????? x1 ?.?.???? TT ??? Serology
all negative Total Weight Gain 10.9 Kg.
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History CC ?????????????? PI
???????????????? 2 ??????? ??????????
???????????? ???????????? ????????????? PH
????????????????? ?????????????? Risk
Postterm
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Physical Examination
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Physical Examination Vital sign stable, HEENT -
normal, HL - normal Uterus - Fundal Height 3/4
gt umbilicus Back of foetus ???????????,
cephalic presentation, FHS ve, EFW 3000
g Pelvic examination Pelvis - adequate
Cervix - soft consistency, effacement 20 ,
os closed NST - reactive
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Labour record
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(No Transcript)
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Labour record (Day 3 after admission) - Abnormal
delivery, position - LOP - Procedure Low F/E
(right mediolateral episiotomy with
subcuticular suture) - Indication thick meconium
amniotic fluid stain - Newborn male, alive,
2850 g, 49.5 cm. APGAR score 1 min. 6 5 min.
9 ???????????? ??????? ET tube for suction ???
??? O2 ?? 2 ???? - Postpartum condition normal
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Progress note
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Progress note

• Postpartum Day 1 (31 ?.?. 44) S
  - O BT 38.3 oc A - P -
• Postpartum Day 2 (1 ?.?. 44) S ????????
  ????? ?????????? ??????????????? O BT 38.2
  oc, BP 120/80 mmHg, PR 88/min. HEENT - not
  pale, no jaundice Heart - normal S1 S2,
  no murmur Lungs - clear Abdomen
  - soft, not tender

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Progress note

• Postpartum Day 2 (cont) O Uterus - 2 FB lt
  umbilicus, well contracted No active
  bleed per vagina A Status postpartum Day 2
  with fever P ??????

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Differential diagnosis

• ????????????????????????????????????
• ????????? ???? ??????
• ????????????????????????????
• ??????????????????????????????
• ????????????????????? ???? ?????????? ???????
• ??????????????????????

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Plan for investigation

• CBC
• UA
• Haemoculture
• Cervical swab for gram stain and culture

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Progress note

• Postpartum Day 3 (2 ?.?. 44) S ????????
  ????? ??????????? ?????????? ????????? ???????
  ?????????? ???????????????????????
  ????????????????????? O BT 38.0 oc
  Perineum - foul-smelling greenish yellow
  discharge per vagina CBC -
  WBC 23400 (Granulocyte 81.8 ) UA -
  within normal limit A F/E postpartum day 3,
  with infected episiotomy wound

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Progress note

• Postpartum Day 3 (cont) P 1. For
  investigation - Pus from wound for gram
  stain - Pus from wound for culture 2. For
  treatment - Stitch off from episiotomy
  wound and dressing bid - Start antibiotic
  (Amoxycilline and Metronidazole p.o.)
  3. Monitor vital signs and clinical vaginal
  bleeding 4. No breast feeding

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Investigation ?? Gram stain Gram negative rod -
few Gram positive cocci - numerous ??
culture for aerobes E.coli - heavy growth
?? Antimicrobial Susceptibility for
E.coli Susceptible to - ampicillin,
amoxycillin, gentamicin, ceftriaxone, etc.
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Clinical improvement after treatment

• Postpartum Day 4 ????????? ????????????????,
  discharge ??????????????????? ??? ??????????
• Postpartum Day 6 ????????? ????? discharge PV
  - MIUB clean episiotomy wound - Vg
  Lochia serosa - Cx clean
  - Ut slightly enlarged - Adx free

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Clinical improvement after treatment

• Postpartum Day 9 S ?????? ????????
  ???????????? ?????????? ??????????
  ???????????? O Perineum - granulation
  tissue form over raw surface, no discharge, no
  foul smell A F/E Status postpartum day 9
  with infected episiotomy wound, clinical
  improved P - 3o suture episiotomy wound at
  OR - continue antibiotic -
  local care

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Puerperal Infection

• Definition ??????????????????????????????????????
  ??????????? ???????????? Puerperal
  morbidity ???????? 38.0 ???????????? ????
  ???????????????? 2 ??? ?????? 10 ??????????????
  ????????? 24 ??????????
• Risk factors ???????????, ??????????????????????,
  PROM, Chorioamnionitis, ?????????????????????????
  ????????????, ????????????????? 12 ???????,
  ????????????????????????, ??????????????

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Puerperal Infection

• Treatment - Specific - Supportive -
  Symptomatic
• Prevention - ????????????????????? - ???
  prophylactic antibiotics ????????????????????
  ???????????????????????????

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Questions
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1. ?????????????????????????? septic abortion
????????????? ???...
A. E.coli
B. Group B beta-haemolytic streptococci
C. Staphylococcal organisms
D. Bacteroides species
E. All of above
E.
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2. Complications ????????????????????? septic
abortion ???...
A. Peritonitis
B. Pelvic Inflammatory Diseases
C. Sepsis
D. Septic shock
E. All of above
E.
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3. ???????????????? ???? 23 ?? ???????????????????
??? 3 ??????? BT 38.3 oc BP 90/60 mmHg PR
128/min. RR 32/min ?????????????????????????????
???...
A. broad-spectrum antibiotic
B. Haemoculture and septic workup
C. Dilation and Curettage
D. Resuscitate volume
E. Ultrasound
D.
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4. ??????????? ???????????????? Puerperal
infection
A. ????????????????????????
B. ?????????????????????????????
C. thick meconium amniotic fluid stain
D. ??????????????????????
E. ?????????????????????????????????????????
C.
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5. ??????????????????????????????? Puerperal
infection
A. mastitis
B. urinary tract infection
C. respiratory tract infection
D. typhoid fever
E. all of above
E.
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The End