Septic abortion: Difference between revisions
No edit summary |
Ostermayer (talk | contribs) No edit summary |
||
Line 1: | Line 1: | ||
==Background== | ==Background== | ||
*Spontaneous or induced abortion that is complicated by a pelvic infection | *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 (2/2 retained products of conception or using non-sterile instruments) | ||
*Endometritis (2/2 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 | *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 | ||
**Clostridium perfringens is associated with a higher mortality | **[[Clostridium]] perfringens is associated with a higher mortality | ||
**Tetanus, especially in developing nations | **[[Tetanus]], especially in developing nations and if nonsterile instrumentation is the cause | ||
===Risk Factors=== | ===Risk Factors=== | ||
* | *Non Sterile abortions | ||
*Advanced gestational age | *Advanced gestational age | ||
===Epidemiology=== | ===Epidemiology=== | ||
*Huge cause of maternal mortality worldwide | *Huge cause of maternal mortality worldwide | ||
*Estimated 20 million unsafe abortions performed worldwide every year; 40% done on women ages 15-24 | *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 | *WHO estimates 68,000 women die every year from unsafe abortions, with septic abortion being the #1 cause of death | ||
*Overall mortality: 20-50% | *Overall mortality: 20-50% | ||
Line 17: | Line 17: | ||
==Clinical Features== | ==Clinical Features== | ||
*Abdominal or pelvic pain | *Abdominal or pelvic pain | ||
*Nausea / | *[[Nausea Vomiting in Pregnancy|Nausea/Vomitting]] | ||
*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 | ||
*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 | ||
==Diagnosis== | ==Diagnosis== | ||
Line 28: | Line 28: | ||
*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 | ||
*Gram stain and culture of any vaginal discharge | *Gram stain and culture of any vaginal discharge | ||
*Check | *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 | ||
*Ultrasound – check for intrauterine material, abdominal free fluid, pelvic abscess | *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 | ||
==Management== | ==Management== | ||
*2 large bore IVs; aggressive IV fluid resuscitation | *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 – Ampicillin 1-2 gm IV + Gentamicin 1-2 mg/kg IV + Clindamycin 600-900 mg IV or Metronidazole 500 mg IV | *Broad-spectrum antibiotics – Ampicillin 1-2 gm IV + Gentamicin 1-2 mg/kg IV + Clindamycin 600-900 mg IV or Metronidazole 500 mg IV | ||
Line 40: | Line 40: | ||
*Early surgery consult - Exploratory laparotomy if any pelvic free fluid or intra-abdominal air | *Early surgery consult - Exploratory laparotomy if any pelvic free fluid or intra-abdominal air | ||
==Complications== | ==Complications== | ||
*Need for hysterectomy and bilateral salpingo-oophorectomy | *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, liver dysfunction, ARDS, multisystem organ failure | *Acute [[Renal Failure|renal failure]], liver dysfunction, [[ARDS]], multisystem organ failure | ||
* | *[[DIC]] | ||
*Hemorrhage requiring transfusion | *Hemorrhage requiring transfusion | ||
*Increased risk of ectopic pregnancy and infertility in the future | *Increased risk of ectopic pregnancy and infertility in the future | ||
==See Also== | ==See Also== | ||
*[[First Trimester Abortion]] | |||
*[[Sepsis]] | |||
*[[PID]] | |||
*[[Endometritis (Postpartum)]] | |||
*[[Vaginal Bleeding Pregnant (greater than 20wks)]] | |||
*[[Vaginal Bleeding Pregnant (less than 20wks)]] | |||
==Sources== | ==Sources== | ||
<references/> | <references/> | ||
[[Category: OB/GYN]] | [[Category: OB/GYN]] |
Revision as of 01:05, 25 August 2014
Background
- Spontaneous or induced abortion that is complicated by a pelvic infection[1]*Endometritis (2/2 retained products of conception or using non-sterile instruments)
- 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/Vomitting
- 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
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 coagulation panel 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[5]
- 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 [6]
- Acute renal failure, liver dysfunction, ARDS, multisystem organ failure
- DIC
- Hemorrhage requiring transfusion
- Increased risk of ectopic pregnancy and infertility in the future
See Also
- First Trimester Abortion
- Sepsis
- PID
- Endometritis (Postpartum)
- Vaginal Bleeding Pregnant (greater than 20wks)
- Vaginal Bleeding Pregnant (less than 20wks)
Sources
- ↑ 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.
- ↑ Osazuwa, Henry, and Michael Aziken. "Septic Abortion: A Review of Social and Demographic Characteristics." Archives of Gynecology and Obstetrics 275.2 (2007): 117-19.
- ↑ Gaufberg, Salva V., MD, and Pamela L. Dyne, MD. "Abortion Complications."Abortion Complications. Medscape, 22 Oct. 2012.