Septic abortion

Background

• Spontaneous or induced abortion that is complicated by a pelvic infection
• Endometritis (2/2 retained products of conception or using non-sterile instruments) => PID and peritonitis => bacteremia, sepsis, and death
• Usually a polymicrobial infection
  • E. Coli, Streptococcus, anaerobes (Bacteroides), sexually transmitted pathogens
  • Clostridium perfringens is associated with a higher mortality
  • Tetanus, especially in developing nations

Risk Factors

• Illegal abortions / unsafe 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
• 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
• Hx 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

Diagnosis

• 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 coags to rule out DIC
• Pelvic exam – look for signs of trauma to cervix or vagina
• 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
• Assess for and control any vaginal bleeding
• Broad-spectrum antibiotics – Ampicillin 1-2 gm IV + Gentamicin 1-2 mg/kg IV + Clindamycin 600-900 mg IV or Metronidazole 500 mg 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

Complications

• Need for hysterectomy and bilateral salpingo-oophorectomy
• Acute renal failure, liver dysfunction, ARDS, multisystem organ failure
• Coagulopathy - DIC
• Hemorrhage requiring transfusion
• Increased risk of ectopic pregnancy and infertility in the future

Sources

1. Finkielman, Javier Daniel, Fabian Dario De Feo, Paula Graciela Heller, and Bekele Afessa. "The Clinical Course of Patients with Septic Abortion Admitted to an Intensive Care Unit." Intensive Care Medicine 30.6 (2004): 1097-102.
2. Gaufberg, Salva V., MD, and Pamela L. Dyne, MD. "Abortion Complications."Abortion Complications. Medscape, 22 Oct. 2012.
3. Osazuwa, Henry, and Michael Aziken. "Septic Abortion: A Review of Social and Demographic Characteristics." Archives of Gynecology and Obstetrics 275.2 (2007): 117-19.
4. 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.
5. 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.
6. Stubblefield, Phillip G., and David A. Grimes. "Septic Abortion." New England Journal of Medicine 331.5 (1994): 310-14.