SURGICAL SURGICAL MANAGEMENT OF MANAGEMENT OF SEPTIC ABORTIONSEPTIC ABORTION

Dr. Jasmine MehtaDr. Jasmine Mehta

M.D.M.D.

Gynecologist, G. K. General hospitalGynecologist, G. K. General hospital

BHUJBHUJ

STATESTICSSTATESTICS

• 10% of all pregnancies end into abortion.• 10% of all abortions admitted to hospital are septic.• % of maternal mortality is due to septic abortions.

DefinitionDefinition

• Any abortion associated with clinical evidences of infection of uterus and its contents is called as septic abortion.

• Clinical evidences of infection are-

1) Fever 38 C or more for at least 24 hrs

2) Offensive or purulent vaginal discharge

3) Lower abdominal pain, tenderness or mass.

4) Tachycardia of more than 100 per min.

Clinical Grading of septic abortionClinical Grading of septic abortion

• Grade 1- Infection localized to uterus• Grade 2- infection beyond uterus to parametrium, tubes ,

ovaries or pelvic peritoneum• Grade 3- generalized peritonitis and or endotoxic shock

or ARF

Indications of surgeryIndications of surgery

• Retained products

• Injury to uterus

• Suspected injury to gut

• Presence of foreign body in abdomen as evidenced by x ray or PV

• Unresponsive peritonitis or pelvic abscess

• Septic shock or oliguria not responding to conservative treatment

Investigations before surgeryInvestigations before surgery

Laboratory investigations:• Complete haemogram• Blood grouping and screening • Urine routine micro and culture sensitivity• UPT• Cervical or high vaginal swab culture• blood culture and sensitivity• RFT and LFT• Coagulation profile- BT ,CT, PT,APTT D-dimer

Investigations before surgeryInvestigations before surgery

Imaging studies• X ray abdomen

standing

• USG abdomen and pelvis

Pre –operative managementPre –operative management• Resuscitation and correction of shock• Broad spectrum antibiotics

better to be guided by culture report later3rd gen cephalosporin+ metronidazole+aminoglycoside

• Blood transfusion: keep at least 2 units of blood ready

• supportive management with IV fluids, antipyretics and analgesics

• Injection TT• Correction of coagulation profile if any• Prophylactic use of anti gas gangrene or anti

tetanus serum

SURGERYSURGERY

Type of surgery needed depends on extent and type of pathology

• E & C• Posterior colpotomy• Laparotomy- to drain pelvic abscess, to

repair uterine perforation, to repair gut injury with or without performing colostomy

• hysterectomy

Types of surgery requiredTypes of surgery required

Evacuation and curettageEvacuation and curettage

• Give antibiotic coverage before 24 hrs of the procedure• If there is heavy bleeding, one may not wait for

completion of 24 hrs of antibiotics• Inj. Prostodin 1 hr before the procedure• Procedure has to be carried out by senior surgeon-

gentle but complete evacuation has to be done• Avoid perforation: it is likely as tissues are very friable• Send the obtained tissue for histopathology and culture• Complications- perforation ,bleeding

Posterior ColpotomyPosterior Colpotomy

• Indication: Pelvic abscess• Requirements for colpotomy drainage the abscess must be In midline adherent to cul de sac peritoneum cystic or fluctuant• Complications False passage Intra peritoneal rupture of abscess bleeding

Method of posterior colpotomyMethod of posterior colpotomy

• Anesthesia, lithotomy position, catheterization

• Examination under anesthesia to confirm area of maximum fluctuation

• Cx grasped and pulled upward and forwards.

• Colpopuncture with wide bore needle on near midline keeping direction of needle in axis of pelvis

• Pus withdrawn and sent for culture

• A transverse incicion of 2cm at the level of colpopuncture

Method of posterior colpotomyMethod of posterior colpotomy

• Blunt kelly’s forceps introduced in POD and opened to allow pus to drain

• Septations in abscess cavity are broken with gloved index finger

• Drain kept and sutured with vaginal vault

• Drain should be removed after 48 hours to prevent pressure necrosis of ant rectal wall

• Avoid extension of incision to laterally to prevent injury to ureter or uterine artery

LAPAROTOMYLAPAROTOMY• Indication Injury to uterus, or gut Presence of foreign body in abdomen Unresponsive peritonitis or pelvic

abscess• Method Transverse Maylard incision is ideal Pelvic adhesion released and bowel

packed off pus drained out and sent for culture Foreign body removed Uterus, adenexa and intestines are

explored for injury or bleeding Uterine perforation repaired in single

layer Intestinal perforation repaired in 2

layers Povidone iodine wash given Drain kept Abdomen closed in layers

LAPAROTOMY IN CASE OF LAPAROTOMY IN CASE OF TUBOOVARIAN ABCCESTUBOOVARIAN ABCCES

• Midline vertical or paramedian incision

• Pus drained and sent for culture

• Omentum and small bowel seperated from T-O mass by gentle blunt dissection with fingers

• Separate ovary and tubes from uterus, sigmoid colon, and broad ligament

LAPAROTOMY IN CASE OF LAPAROTOMY IN CASE OF TUBOOVARIAN ABCCESTUBOOVARIAN ABCCES

• Apply clamps• Clamp-1 Infundibulopelvic

ligament• Clamp-2 Broad ligament

below ovary• Clamp-3 Fallopian tube and

ovarian tube and ovary removed, wash given , sdrain kept

• Abdomen closed in layers

HYSTERECTOMYHYSTERECTOMY

• Indication• Irreparable injury to uterus

bilateral tuboovarian abscess• Spreading gas gangrene

infection in uterus

• Method• Maylard or midline incision• Pus drained out• Separate T-O masses from

bowel, back of uterus, POD and broad ligament by upward and lateral maneuvering

• First round ligament identified and ligated

HYSTERECTOMYHYSTERECTOMY

• Ant fold of peritoneum opened

• Infundibulopelvic ligament ligated

• Due precaution for ureter• Subtotal hysterectomy

may have to be done• Vaginal vault kept open

for draiage• Abdomen closed in layers