Septic abortion: Difference between revisions
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==Background== | ==Background== | ||
*Spontaneous or induced abortion that is complicated by a pelvic infection<ref>Stubblefield, Phillip G., and David A. Grimes. "Septic Abortion." New England Journal of Medicine 331.5 (1994): 310-14.</ref>*Endometritis ( | *Spontaneous or induced abortion that is complicated by a pelvic infection<ref>Stubblefield, Phillip G., and David A. Grimes. "Septic Abortion." New England Journal of Medicine 331.5 (1994): 310-14.</ref> | ||
**Leading to [[PID]] and peritonitis then bacteremia, sepsis, and death<ref>Finkielman, Javier et al. "The Clinical Course of Patients with Septic Abortion Admitted to an Intensive Care Unit." Intensive Care Medicine 30.6 (2004): 1097-102.</ref> | *[[Endometritis]] (secondary to [[retained products of conception]] or using non-sterile instruments) | ||
**Leading to [[PID]] and [[peritonitis]] then [[bacteremia]], [[sepsis]], and death<ref>Finkielman, Javier et al. "The Clinical Course of Patients with Septic Abortion Admitted to an Intensive Care Unit." Intensive Care Medicine 30.6 (2004): 1097-102.</ref> | |||
*Usually a polymicrobial infection<ref>Tintinalli, Judith E., and J. Stephan. Stapczynski. "Septic Abortion." Tintinalli's Emergency Medicine: A Comprehensive Study Guide. 7th ed. New York: McGraw-Hill, 2011. 682.</ref> | *Usually a polymicrobial infection<ref>Tintinalli, Judith E., and J. Stephan. Stapczynski. "Septic Abortion." Tintinalli's Emergency Medicine: A Comprehensive Study Guide. 7th ed. New York: McGraw-Hill, 2011. 682.</ref> | ||
**[[E. Coli]], [[Streptococcus]], [[anaerobes]] (Bacteroides), sexually transmitted pathogens | **[[E. Coli]], [[Streptococcus]], [[anaerobes]] (Bacteroides), sexually transmitted pathogens | ||
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==Clinical Features== | ==Clinical Features== | ||
*Abdominal or pelvic pain | *[[abdominal pain|Abdominal]] or [[pelvic pain]] | ||
*[[Nausea Vomiting in Pregnancy|Nausea/ | *[[Nausea Vomiting in Pregnancy|Nausea/Vomiting]] | ||
*[[Vaginal_Bleeding_Pregnant_(less_than_20wks)|Vaginal bleeding]] | *[[Vaginal_Bleeding_Pregnant_(less_than_20wks)|Vaginal bleeding]] | ||
*Vaginal discharge | *[[Vaginal discharge]] | ||
*Cervical motion tenderness | *Cervical motion tenderness | ||
*[[Hypotension]], tachycardia, fever, tachypnea | *[[Hypotension]], [[tachycardia]], [[fever]], [[tachypnea]] | ||
*History of recent pregnancy or known induced or spontaneous abortion | *History of recent pregnancy or known induced or spontaneous abortion | ||
*Usually delayed presentation (48 hours after onset of symptoms) secondary to the stigma of induced abortion | *Usually delayed presentation (48 hours after onset of symptoms) secondary to the stigma of induced abortion | ||
===Complications=== | |||
*Need for hysterectomy and bilateral salpingo-oophorectomy <ref>Gaufberg, Salva V., MD, and Pamela L. Dyne, MD. "Abortion Complications."Abortion Complications. Medscape, 22 Oct. 2012.</ref> | |||
*Acute [[Renal Failure|renal failure]], liver dysfunction, [[ARDS]], multisystem organ failure | |||
*[[DIC]] | |||
*[[Hemorrhage]] requiring [[pRBCs|transfusion]] | |||
*Increased risk of [[ectopic pregnancy]] and infertility in the future | |||
==Differential Diagnosis== | ==Differential Diagnosis== | ||
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{{VB DDX greater than 20}} | {{VB DDX greater than 20}} | ||
== | ==Evaluation== | ||
*Clinical diagnosis; patient may be reluctant to share information that she had an unsafe abortion | *Clinical diagnosis; patient may be reluctant to share information that she had an unsafe abortion | ||
*Labs: CBC, blood type with Rh status, CMP, serum beta-hcg level, UA, blood cultures | *Labs: CBC, blood type with Rh status, CMP, serum beta-hcg level, UA, blood cultures | ||
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*Check coagulation panel to rule out [[DIC]] | *Check coagulation panel to rule out [[DIC]] | ||
*Pelvic exam – look for signs of trauma to cervix or vagina | *Pelvic exam – look for signs of trauma to cervix or vagina | ||
* | *[[Pelvic ultrasound]] – check for intrauterine material, abdominal free fluid, pelvic [[abscess]] | ||
*CT or MRI – may show uterine emphysema or intraperitoneal air if uterine perforation has occurred | *CT or MRI – may show uterine emphysema or intraperitoneal air if uterine perforation has occurred | ||
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*2 large bore IVs; aggressive IV fluid resuscitation<ref>Osazuwa, Henry, and Michael Aziken. "Septic Abortion: A Review of Social and Demographic Characteristics." Archives of Gynecology and Obstetrics 275.2 (2007): 117-19. </ref> | *2 large bore IVs; aggressive IV fluid resuscitation<ref>Osazuwa, Henry, and Michael Aziken. "Septic Abortion: A Review of Social and Demographic Characteristics." Archives of Gynecology and Obstetrics 275.2 (2007): 117-19. </ref> | ||
*Assess for and control any vaginal bleeding | *Assess for and control any vaginal bleeding | ||
*Broad-spectrum antibiotics – | *Broad-spectrum antibiotics – [[ampicillin]] 1-2 gm IV + [[gentamicin]] 1-2mg/kg IV + [[clindamycin]] 600-900mg IV or [[metronidazole]] 500mg IV | ||
*[[Tetanus]] vaccination | *[[Tetanus]] vaccination | ||
*Early OB consult – Most will need evacuation of any remaining products of conception | *Early OB consult – Most will need evacuation of any remaining products of conception | ||
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==Disposition== | ==Disposition== | ||
*Admit | *Admit | ||
==See Also== | ==See Also== | ||
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<references/> | <references/> | ||
[[Category: | [[Category:OBGYN]] |
Revision as of 17:49, 4 October 2019
Background
- Spontaneous or induced abortion that is complicated by a pelvic infection[1]
- Endometritis (secondary to retained products of conception or using non-sterile instruments)
- Leading to PID and peritonitis then bacteremia, sepsis, and death[2]
- Usually a polymicrobial infection[3]
- E. Coli, Streptococcus, anaerobes (Bacteroides), sexually transmitted pathogens
- Clostridium perfringens is associated with a higher mortality
- Tetanus, especially in developing nations and if nonsterile instrumentation is the cause
Risk Factors
- Non Sterile abortions
- Advanced gestational age
Epidemiology
- Huge cause of maternal mortality worldwide
- Estimated 20 million unsafe abortions performed worldwide every year; 40% done on women ages 15-24[4]
- WHO estimates 68,000 women die every year from unsafe abortions, with septic abortion being the #1 cause of death
- Overall mortality: 20-50%
- Mortality rare in US (1 in 100,000 abortions)
Clinical Features
- Abdominal or pelvic pain
- Nausea/Vomiting
- Vaginal bleeding
- Vaginal discharge
- Cervical motion tenderness
- Hypotension, tachycardia, fever, tachypnea
- History of recent pregnancy or known induced or spontaneous abortion
- Usually delayed presentation (48 hours after onset of symptoms) secondary to the stigma of induced abortion
Complications
- Need for hysterectomy and bilateral salpingo-oophorectomy [5]
- Acute renal failure, liver dysfunction, ARDS, multisystem organ failure
- DIC
- Hemorrhage requiring transfusion
- Increased risk of ectopic pregnancy and infertility in the future
Differential Diagnosis
Abdominal Pain in Pregnancy
The same abdominal pain differential as non-pregnant patients, plus:
<20 Weeks
- Ectopic pregnancy
- First trimester abortion
- Complete abortion
- Threatened abortion
- Inevitable abortion
- Incomplete abortion
- Missed abortion
- Septic abortion
- Round ligament stretching
- Incarcerated uterus
- Malposition of the uterus
>20 Weeks
- Labor/Preterm labor
- Placental abruption
- Placenta previa
- Vasa previa
- Uterine rupture
- Vaginal trauma
- HELLP syndrome
- Cholestasis of pregnancy
- Chorioamnionitis
- Incarcerated uterus
- Acute fatty liver of pregnancy
- Malposition of the uterus
- Placenta accreta
- Placenta increta
- Placenta percreta
Any time
- Hemorrhagic ovarian cyst
- Fibroid degeneration or torsion
- Ovarian torsion
- Constipation
Vaginal Bleeding in Pregnancy (>20wks)
- Emergent delivery
- Placental abruption
- Placenta previa
- Vasa previa
- Uterine rupture
- Preterm labor
- Vaginal trauma
- Placenta accreta
- Intrauterine fetal demise
Evaluation
- Clinical diagnosis; patient may be reluctant to share information that she had an unsafe abortion
- Labs: CBC, blood type with Rh status, CMP, serum beta-hcg level, UA, blood cultures
- Gram stain and culture of any vaginal discharge
- Check coagulation panel to rule out DIC
- Pelvic exam – look for signs of trauma to cervix or vagina
- Pelvic ultrasound – check for intrauterine material, abdominal free fluid, pelvic abscess
- CT or MRI – may show uterine emphysema or intraperitoneal air if uterine perforation has occurred
Management
- 2 large bore IVs; aggressive IV fluid resuscitation[6]
- Assess for and control any vaginal bleeding
- Broad-spectrum antibiotics – ampicillin 1-2 gm IV + gentamicin 1-2mg/kg IV + clindamycin 600-900mg IV or metronidazole 500mg IV
- Tetanus vaccination
- Early OB consult – Most will need evacuation of any remaining products of conception
- Early surgery consult - Exploratory laparotomy if any pelvic free fluid or intra-abdominal air
Disposition
- Admit
See Also
- First Trimester Abortion
- Sepsis
- PID
- Endometritis (Postpartum)
- Vaginal Bleeding Pregnant (greater than 20wks)
- Vaginal Bleeding Pregnant (less than 20wks)
References
- ↑ Stubblefield, Phillip G., and David A. Grimes. "Septic Abortion." New England Journal of Medicine 331.5 (1994): 310-14.
- ↑ Finkielman, Javier et al. "The Clinical Course of Patients with Septic Abortion Admitted to an Intensive Care Unit." Intensive Care Medicine 30.6 (2004): 1097-102.
- ↑ Tintinalli, Judith E., and J. Stephan. Stapczynski. "Septic Abortion." Tintinalli's Emergency Medicine: A Comprehensive Study Guide. 7th ed. New York: McGraw-Hill, 2011. 682.
- ↑ Saultes, Teresa A., Devita, Diane., Heiner, Jason D. “The Back Alley Revisited: Sepsis after Attempted Self-Induced Abortion.” Western Journal of Emergency Medicine 10, 4 (2009) 278-280.
- ↑ Gaufberg, Salva V., MD, and Pamela L. Dyne, MD. "Abortion Complications."Abortion Complications. Medscape, 22 Oct. 2012.
- ↑ Osazuwa, Henry, and Michael Aziken. "Septic Abortion: A Review of Social and Demographic Characteristics." Archives of Gynecology and Obstetrics 275.2 (2007): 117-19.