Septic Abortion

Septic abortion. Septic abortion is defined as an ascending infectious process characterized by endometritis, adnexitis and parametris due to ovular contamination during abortive maneuvers or due to spontaneous rupture of the ovular membranes. Risk factors are advanced pregnancy, lack of adequate asepsis, technical difficulties in uterine evacuation or the unsuspected presence of sexually transmitted pathogens or germs of the potentially normal flora of the vagina, endocervix, external genitalia and perineal region, which are made up of Enterobacteria, Pseudomonas, anaerobes such as Bacteroides and Clostridium. Clinically, local or regional signs of infection such as pelviperitonitis, diffuse peritonitis, pelvic thrombophlebitis and / or signs of dissemination of microorganisms or their toxins (sepsis,liver , lung and kidney from sepsis, coagulation disorders , encephalopathy, gastrointestinal bleeding). The activation of inflammatory mediators are those that cause, within a wide spectrum of disastrous consequences, hemolysis and severe shock, with the possibility of evolving to SIMO, a condition that contains a very high mortality.

Summary

[ hide ]

  • 1 Terminology
  • 2 Clinical concept
  • 3 Clinical Picture
  • 4 Demographic considerations
  • 5 Most Used Abortive Methods
  • 6 Predisposing etiological factors
    • 1 Complications of induced abortion
    • 2 Common germs that cause septic abortions
    • 3 Pathways of propagation
  • 7 Pathophysiology
  • 8 Clinic
    • 1 General Manifestations
    • 2 Local Demonstrations
    • 3 Pathological changes
    • 4 Anaerobic infection
    • 5 Clostridium perfringens infection
  • 9 Classification of septic abortion
  • 10 Bad prognosis
  • 11 Complications
  • 12 Diagnosis
  • 13 Conduct and treatment
    • 1 Antibiotic therapy
      • 1.1 Dose of antibiotics
    • 14 Elimination of the septic source
      • 1 In the first 12 hours
      • 2 Indications for laparotomy
      • 3 Indications for hysterectomy
    • 15 Sources

Terminology

The term abortion, from the gynecological-obstetric point of view, refers to the interruption of pregnancy before 120 days, that is, until the end of the fourth month. Another definition speaks of the expulsion of the egg before it is viable. This slightly broader definition includes immature labor in its terms, since it takes this period until the 28th week of gestation. Thus considered, we must also say that one can speak of spontaneous abortion or induced abortion. Obviously the issue that brings us together is focused on induced abortions, and of these are mostly those that are called criminals. Induced abortion (for criminal purposes) has its legal framework and is specifically cited in the Penal Code, in its articles 85, 86, 87 and 88. From the criminal point of view, abortion is a crime against the life of people, in this case, of an unborn person. From the medical legal point of view, it is about the death of the product of conception, at any time during pregnancy.

Clinical concept

 

Infection and Monitoring

It is an abortive process accompanied by 2 or more of the following clinical characteristics:

  • Hyperthermia
  • Hypogastric pain
  • Vaginal leaks
  • Recognition of abortive maneuvers
  • Indicators of clinical severity or complications
  • Others: Hypotension , leukocytosis > 15,000 mm3

Clinical Picture

You are facing a septic abortion , the infection has spread through the lymphatic, hematic and / or canalicular routes. The septic picture is caused by the bacterial invasion itself, but also by endotoxemia secondary to that invasion. Focal signs of infection such as pelviperitonitis, or disseminated peritonitis with abdominal peritoneal reaction, may be seen in cases of uterine perforation. Thrombophlebitis may appearpelvic which can be manifested by edema of both legs and pelvic pain. But the distinctive sign of this condition is the systemic involvement by sepsis, a direct result of the infection, primarily and secondarily maintained and magnified by the activation of inflammatory mediators. The patient presents with fever, alterations in mental status, from stupor to psychomotor excitement, and may give neurological focus if there has been septic embolism. From the hemodynamic point of view, as is well known, the septic picture goes through different stages, first the so-called hidden shock that can be manifested by changes in blood pressure, restlessness, restlessness without apparent cause, variations in oxemia, etc. The so-called hot phase of sepsis composed of a hyperdynamic syndrome:Tachycardia , with increased minute volume with low peripheral resistance. This condition, without a favorable response to treatment, progresses to the cold phase of sepsis (septic shock) with progressive deterioration of the entire hemodynamics: severe myocardial depression, treatment-refractory hypotension, decreased minute volume and low peripheral resistance. To all this hemodynamic catastrophe is added the sequential fall of the other devices, thus constituting the SIMO, so it is possible to observe acute respiratory distress (ARDS), upper or lower gastrointestinal bleeding (HDA-HDB), anuric acute renal failure or not (ARF), liver dysfunction manifested by coagulation disorders, hypoalbuminemia, increased transaminases, hyperbilirubinemia and hepatic encephalopathy.

Demographic considerations

It occurs more frequently in children under 20 years of age, primiparous, single and during the first trimester of pregnancy.

Most used abortive methods

  • Instrumental evacuation of the uterus
  • Induction of uterine contractions
  • Uterine surgery

Predisposing etiological factors

  • Amniotic hydrorrhea
  • Retention of ovular remains
  • Retained dead egg
  • Abortion

Complications of induced abortion

  • Uterine perforations
  • Bleeding
  • Infections

They depend on:

  • Gestational age
  • Place where the abortive maneuver was performed
  • Person who performed the procedure
  • Method used
  • Latency period

Frequent germs that cause septic abortions

  • Gram negative:

Echerichia coli, Klebssiella, Proteus, Enterobacter, Pseudomona aeruginosa, Bacterioides fragilis.

  • Gram positive:

Streptococci, Staphylococci, Clostridium perfringens, Pepto-streptococcus.

Pathways of propagation

  • By ascending route
  • By contiguity
  • Through the lymphatic or venous route
  • By blood route

Pathophysiology

  • Localized infection
  • Spread septic infection
  • Generalized septic infection

Clinic

  • Mondor triad (coppery skin, vinous urine, characteristic color of plasma)
  • Hepato-renal insufficiency
  • Feeling of impending doom

Background :

  • Short-term amenorrhea
  • Abortion at any stage of development
  • Patient reports accidental trauma or expulsion of ovular remains.

General manifestations

General hyperthermia preserved severe symptoms, neurological alteration, hypotension, tachypnea and complications.

Local manifestations

  • Pain
  • Modified vaginal leaks
  • Provocative injuries

Pathological changes

  • Acute inflammatory changes
  • Edema
  • Thrombosis
  • Abscesses
  • Necrosis
  • Fibrosis
  • Cellulitis

Anaerobic infection

  • Stench
  • Necrosis
  • Abscesses or gas
  • Jaundice
  • Proximity of mucosal surfaces

Clostridium perfringens infection

  • Myotoxins
  • Neurotoxins
  • Hyaluronidase
  • Dermo-necrotizing lesions
  • Jaundice
  • Bleeding
  • Anemia
  • Hemolysis

Classification of septic abortion

GRADE I: Localized infection in the uterine cavity GRADE II: Infection that only spreads to other pelvic structures GRADE III: Disseminated infection associated with:

  • Septicemia or sepsis
  • Pelviperitonitis
  • Pelvic thrombophlebitis
  • Septic shock complicated with ARI or CID

Bad prognosis

  • Consciousness disorders
  • Hypothermia
  • Hypotension
  • Sustained hyperthermia
  • Sustained bradycardia
  • Respiratory distress
  • Severe complications: septic shock, ARF, DIC
  • Persistent leukocytosis

Complications

  • Uterine perforations
  • Septic shock: metabolic and hemodynamic alterations and cell death
  • Acute Respiratory Infections (ARI)
  • Pelviperitonitis
  • Disseminated Intravascular Coagulation (DIC)
  • Water and electrolyte disorders

Diagnosis

  1. Anamnesis
  2. Physical exam
  3. Complementary exams:
  • Blood group and Rh factor
  • Complete hematology
  • Kidney and liver function tests
  • Coagulation screen
  • Urine test
  • Cultures , urine culture and antibiogram
  • Rx and ultrasound

Behavior and treatment

  • Hospitalization
  • Hydration
  • Tetanus toxoid
  • Diuresis control
  • Laboratory: HC, PT, PTT, U, C, BB, TGO, TGP, gases and electrolytes, culture and antibiogram.
  • Control of vital signs
  • Control of income and expenses
  • Antibiotic therapy
  • Elimination of the septic source

Antibiotic therapy

  1. Crystalline penicillin + aminoglycoside
  2. Chloramphenicol + aminoglycoside
  3. Cephalosporin 2nd. or 3rd. + aminoglycoside
  4. Clindamycin + aminoglycoside
  5. Ampicillin + aminoglycoside
  6. Metronidazole + aminoglycoside
  7. Penicillin + aminoglycoside + chloramphenicol
  8. Metronidazole + aminoglycoside + clindamycin

Antibiotic dosage

All by endovenous route

  1. Crystalline penicillin:
  • Mild cases: 4 mill U / 4 h
  • Severe cases: initial dose of 10 million U followed by 4 million U / 4 h
  1. Gentamicin : 80 mg / 8 h
  2. Amikacin : 500 mg / 12 h
  3. Chloramphenicol: 500 mg – 1 gr / 6 h
  4. Metronidazole: 500 mg / 6 h
  5. Aztreonam : 1 – 2 gr / 8 – 12 h
  6. Ampicillin sulbactam: 1.5 gr / 8 h
  7. Ceftazidime : 1 gr / 8 h

Elimination of the septic source

In the first 12 hours

  1. Uterine aspiration
  2. Uterine curettage
  3. Exploratory laparotomy
  4. Hysterectomy

Indications for laparotomy

  • Persistence of the septic picture
  • Uterine perforation
  • Generalized peritonitis
  • Bulging of the cul-de-sac of Douglas to the touch

Indications for hysterectomy

  • When the size of the uterus corresponds to a pregnancy greater than 14 weeks
  • perfringens infection
  • Multiple uterine perforations, lasting longer than 24 hours
  • Tubal abscesses or pelviperitonitis
  • Abortions caused by soapy or caustic solutions
  • Irreversible septic shock

 

Leave a Comment