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