Septic Abortion

SEPTIC ABORTION BY DR. JAMES E. OMIETIMI

INTRODUCTION

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More than 60% of pregnancies end in spontaneous abortion. Most pregnancies are lost in the early weeks of pregnancy than at any other stage of gestation, with 80% of spontaneous abortions occurring prior to 12 weeks gestation. The WHO estimates that about 46 million cases of abortion occur annually About 90-95% of this figure occurs in the developing countries and more than 80% of these are unsafe abortions, often

DEFINITION 

Abortion is the termination of pregnancy before fetal viability, usually taken in our environment to be the 28th week of gestation.

OR By the W.H.O. The expulsion or extraction of the embryo or

EPIDEMIOLOGY

It is virtually impossible to state an accurate frequency of spontaneous abortions, because some of the early cases are not definitely diagnosed and may be regarded as abnormal menstrual period. The incidence of spontaneous abortions is generally estimated to be 15-17 % of all pregnancies. 5 per 1000 women in Holland. The incidence in Nigeria is about 610,000 P.A., accounting for 40% of the cases in W.A., 25 per 1000 women aged 15-45years. Commonest gynaecologic admission in U.P.T.H. accounting for (27%) 137 out of 502. (2003

AETIOPATHOLOGY

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The aetiology is unknown in majority of cases. Most 1st trimester abortions are due to an abnormal karyotype while later abortions are due to chromosomal abnormalities and maternal factors. Aneuploidy- (an abnormal chromosome number) 50% of cases Autosomal trisomies- all chromosomes, except 1, with trisomy 16, being the most common. Monosomy X or Turner’s syndrome is the commonest aneuploidy in spontaneous abortions- 20% of all. Polyploidy in the form of triploidy accounts for 20%. They typically result in blighted ovums or

Aetiopathology Continued. Maternal infections/infestations UTI, Malaria, Pyelonephritis, Appendicitis, Listeria monocytogenes. Trepanoma pallidum TORCH organisms. Maternal Diseases; Diabetes Mellitus Hypertensive Diseases Renal diseases Systemic lupus erythromatosis Hypothyroidism Hyperthyroidism Wilson Disease

Aetiopathology continued UTERINE DEFECTS; unicornuate, bicornuate, septate uteri. Diethlstilbesterol (DES)-related anomaly such as T-shaped or hypoplastic uteri Acquired anomalies-uterine fibroids, Asherman’s syndrome Cervical Incompetence MALNUTRITION; Severe malnutrition TRAUMA; Direct trauma such as injury to the uterus e.g. Gunshot injury or Indirect trauma such as surgical removal of an ovary containing a

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AETIOPATHOLOGY Continued IMMUNOLOGIC DISORDERS;

ABO, Rh, Kell etc Similar maternal and paternal HLA may enhance the possibility of abortion by causing insufficient maternal immunologic recognition of the fetus. TOXIC FACTORS; Radiation Anti-neoplastic agents Anaesthetic agents Alcohol Nicotine Lead Ethylene oxide

CLINICAL VARIETIES OF ABORTION

THREATENED ABORTION; At least 20% of pregnant women have some first trimester bleeding. Usually thought to be implantation bleed The cevical os is usually closed There is no associated painful uterine contraction INEVITABLE ABORTION; Increased vaginal bleeding Associated with painful uterine contractions, lower abdominal or back pain There is cervical effacement and dilatation

INCOMPLETE ABORTION; The products of conception have been partially passed from the uterine cavity Usually associated with abdominal cramps When infected leads to septic abortion. Bleeding is generally persistent and if severe may lead to shock. COMPLETE ABORTION; All the products of conception have 

MISSED ABORTION The embryo dies but the gestational sac and embryo are retained in the uterus for several weeks or months. Symptoms and signs of pregnancy disappear. Immunological tests for pregnancy usually become negative about 10 days after the death of the embryo Disseminated Intravascular Coagulation 

SEPTIC ABORTION     

Presence of an intrauterine infection following an abortion; 1. This may be due to infected retained products of conception. 2. Use of non sterile instruments to procure abortion 3. Uterine perforation with spillage of intestinal contents. ORGANISMS; E.coli, streptococci, staph. Aureus, proteus, pseudomonas, pneumococci, klebsiella, Chlamydia trachomatis, Neisseria gonorrhoea,

CLINICAL PRESENTATION

HISTORY: Hx. of an abortion may or may not be volunteered There is usually high grade fever Generalized, Suprapubic, lower abdominal or low back pain Offensive vaginal discharge EXAMINATION: General-Pale, febrile, jaundiced, furred tongue, offensive CVStachycardia and hypotension Abdomen- guarding, tenderness; 

EXAMINATION continued. 

V/E: There may or may not be bruises on vulva Vagina is usually hot Cervical Os may be open or closed Uterus and adnaexae are usually tender Pouch of Douglas may be full and tender Cervical motion tenderness is usually positive Gloved examining fingers are usually stained with offensive

COMPLICATIONS

Immediate; Anaemia from haemorrhage Endotoxic shock Acute renal failure Death Long Term; Chronic PID Chronic tubo-ovarian masses/abscesses Chronic vaginal discharge Chronic pelvic pain Dyspareunia Tubal occlusion with secondary Infertility Ectopic pregnancy Asherman’s syndrome Adhesions with intestinal obstruction 