SURGICAL MANAGEMENT OF SEPTIC ABORTION

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Information about SURGICAL MANAGEMENT OF SEPTIC ABORTION

Published on July 28, 2008

Author: nehjasmine

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SURGICAL MANAGEMENT OF SEPTIC ABORTION

SURGICAL MANAGEMENT OF SEPTIC ABORTION Dr. Jasmine Mehta M.D. Gynecologist, G. K. General hospital BHUJ

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

10% of all pregnancies end into abortion.

10% of all abortions admitted to hospital are septic.

% of maternal mortality is due to septic abortions.

Definition Any abortion associated with clinical evidences of infection of uterus and its contents is called as septic abortion. Clinical evidences of infection are- Fever 38 C or more for at least 24 hrs Offensive or purulent vaginal discharge Lower abdominal pain, tenderness or mass. Tachycardia of more than 100 per min.

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

Clinical evidences of infection are-

Fever 38 C or more for at least 24 hrs

Offensive or purulent vaginal discharge

Lower abdominal pain, tenderness or mass.

Tachycardia of more than 100 per min.

Clinical 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

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 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

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 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

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 surgery Imaging studies X ray abdomen standing USG abdomen and pelvis

Imaging studies

X ray abdomen standing

USG abdomen and pelvis

Pre –operative management Resuscitation and correction of shock Broad spectrum antibiotics better to be guided by culture report later 3 rd 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

Resuscitation and correction of shock

Broad spectrum antibiotics

better to be guided by culture report later

3 rd 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

SURGERY 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

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 required

Evacuation 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

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 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

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 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

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 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

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

LAPAROTOMY 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

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 TUBOOVARIAN 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

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 TUBOOVARIAN 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

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

HYSTERECTOMY 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

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

HYSTERECTOMY 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

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

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