Difference between revisions of "Septic abortion"

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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]] (secondary to [[retained products of conception]] or using non-sterile instruments)
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**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>
 +
**[[E. Coli]], [[Streptococcus]], [[anaerobes]] (Bacteroides), sexually transmitted pathogens
 +
**[[Clostridium]] perfringens is associated with a higher mortality
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**[[Tetanus]], especially in developing nations and if nonsterile instrumentation is the cause
 +
 +
===Risk Factors===
 +
*Non Sterile abortions
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*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<ref>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. </ref>
 +
*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==
 
==Clinical Features==
 +
*[[abdominal pain|Abdominal]] or [[pelvic pain]]
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*[[Nausea Vomiting in Pregnancy|Nausea/Vomiting]]
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*[[Vaginal_Bleeding_Pregnant_(less_than_20wks)|Vaginal bleeding]]
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*[[Vaginal discharge]]
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*Cervical motion tenderness
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*[[Hypotension]], [[tachycardia]], [[fever]], [[tachypnea]]
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*History of recent pregnancy or known induced or spontaneous abortion
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*Usually delayed presentation (48 hours after onset of symptoms) secondary to the stigma of induced abortion
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 +
===Complications===
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*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
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*[[DIC]]
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*[[Hemorrhage]] requiring [[pRBCs|transfusion]]
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*Increased risk of [[ectopic pregnancy]] and infertility in the future
  
 
==Differential Diagnosis==
 
==Differential Diagnosis==
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{{Abdominal Pain Pregnancy DDX}}
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 +
{{VB DDX greater than 20}}
  
==Workup==
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==Evaluation==
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*Clinical diagnosis; patient may be reluctant to share information that she had an unsafe abortion
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*Labs: CBC, blood type with Rh status, CMP, serum beta-hcg level, UA, blood cultures
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*Gram stain and culture of any vaginal discharge
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*Check coagulation panel to rule out [[DIC]]
 +
*Pelvic exam – look for signs of trauma to cervix or vagina
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*[[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==
 
==Management==
 +
*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
 +
*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==
 
==Disposition==
 +
*Admit
  
 
==See Also==
 
==See Also==
 +
*[[First Trimester Abortion]]
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*[[Sepsis]]
 +
*[[PID]]
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*[[Endometritis (Postpartum)]]
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*[[Vaginal Bleeding Pregnant (greater than 20wks)]]
 +
*[[Vaginal Bleeding Pregnant (less than 20wks)]]
  
==External Links==
+
==References==
 +
<references/>
  
==Sources==
+
[[Category:OBGYN]]
<references/>
 

Latest revision as of 17:49, 4 October 2019

Background

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

Complications

Differential Diagnosis

Abdominal Pain in Pregnancy

The same abdominal pain differential as non-pregnant patients, plus:

<20 Weeks

>20 Weeks

Any time

Vaginal Bleeding in Pregnancy (>20wks)

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

References

  1. Stubblefield, Phillip G., and David A. Grimes. "Septic Abortion." New England Journal of Medicine 331.5 (1994): 310-14.
  2. 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.
  3. 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.
  4. 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.
  5. Gaufberg, Salva V., MD, and Pamela L. Dyne, MD. "Abortion Complications."Abortion Complications. Medscape, 22 Oct. 2012.
  6. Osazuwa, Henry, and Michael Aziken. "Septic Abortion: A Review of Social and Demographic Characteristics." Archives of Gynecology and Obstetrics 275.2 (2007): 117-19.