Review Note
Last Update: 03/02/2025 10:14 AM
Current Deck: ACG Part 2::Obstetrics
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Commit #292869
SS_OB 1.19 Describe the anaesthetic management of early pregnancy conditions such as septic abortion
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Commit #292869Septic abortion:
- Septic abortion typically refers to pregnancies of < 20 weeks gestation while those ≥ 20 weeks gestation with intrauterine infection are usually described as having intra-amniotic infection.
Septic abortion is an infection of the uterus (endometritis) following either:
- Spontaneous abortion (miscarriage)
- Induced abortion
- Surgical
- Unsafe (i.e non-qualified surgical attempts)
- Medical abortion (rarely).
- Infection may spread, causing bacteraemia, peritonitis with septic shock and death.
- Septic abortion is a true medical emergency.
- Pathology:
- Endometritis may extend into the myometrium and parametrium, and progress beyond the uterus, causing peritonitis, pelvic thrombophlebitis, septic shock and death.
- Organisms:
- Septic abortion is usually a polymicrobial infection.
- These can include: Streptococcus pyogenes (group A streptococcus), Staphylococci, Anaerobic bacteria. Clostridium species, Gram negative species; predominantly Enterobacteriaceae / enterococci.
- Less commonly: Chlamydia trachomatis, Neisseria gonorrhoeae, Mycoplasma genitalium,
Clinical features include :
- Vital signs
- Fever (38°C or more)
- Tachycardia
- Tachypnea
- Hypotension if septic / critically unwell
- Abdominal pain / tenderness
- Vaginal bleeding
- Purulent vaginal discharge may be present
- Signs of frank peritonitis, when there has been spread to the peritoneum:
- Abdominal guarding
- Abdominal rigidity
- Vaginal examination may reveal:
- Purulent discharge
- Vaginal or cervical lacerations from instrumentation
- Cervical dilation
- Products of conception
- Cervical motion tenderness
- Uterine/ fundal tenderness.
Investigations
Blood tests:
- FBC: Anemia, Leukocytosis
- CRP: Elevation helps to confirm infection.
- U&E/ glucose
- Blood cultures, (both aerobic and anaerobic).
- Beta-HCG:
- This may be considered in a suspected case of non-medical abortion, in a woman reluctant to disclose a history of abortion or uterine manipulation based on concerns of judgment or legal consequences.
- If the beta-HCG is still elevated or somewhat elevated then this suspicion would be supported. - Additionally patients presenting with infection in the setting of pregnancy loss may not be aware that they are or have recently been pregnant (e.g early pregnancy loss may be perceived simply as a late period).
- Blood grouping.
For unwell septic patients:
- Coagulation studies
- VBGs/ lactate
- Blood cross match
Ultrasound
A pelvic ultrasound may be helpful to exclude the presence of retained products of conception or a tubo-ovarian abscess.
Helpful but: Ultrasound cannot definitively diagnose, septic abortion. Normal USS doesn’t exclude septic abortion.
Management:
Pre-op:
- Place large bore IVL’s and begin resuscitation addressing ABC’s
- Will need to be discussed at some point with ICU but should not delay treatment
- Antibiotics (broad spectrum) usually triple therapy as per peritonitis: Gent/ceftriaxone, ampicillin, metronidazole, need to be started prior to surgical evacuation
Intra-op:
- GA +/- RSI and ETT
- Consider A-line if haemodynamically unstable
- Consider rapid infusor if significant bleeding
- Neuraxial relatively contraindicated in sepsis so avoid as able
- Multi-modal analgesia, opioids, regional e.g. rectus sheath catheters if laparotomy (although source of infection)
- Surgical: Uterine evacuation of necrotic and infected material from the uterus
- Vacuum or suction aspiration is the preferred technique.
- Sharp curettage is contraindicated in septic abortions.
- Laparotomy:
- Indications for laparotomy and hysterectomy include:
- Patients who have received adequate treatment with antibiotics and uterine evacuation without clinical response
- Suspected uterine perforation including bowel injury / pelvic abscess
- Suspected clostridial myometritis
- A hysterectomy should be performed in the case of a necrotic or woody-appearing uterus, signs of gas in the pelvic tissue (either on imaging or with crepitus), or uncontrolled bleeding from the uterus.
Post-op:
- Disposition: Will need ICU support for haemodynamics and monitoring
- Analgesia: Multimodal +/- PCA if laparotomy +/- regional catheters if used