Septic abortion

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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]

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

Differential Diagnosis

Abdominal Pain in Pregnancy

The same abdominal pathologies as non-pregnant patients, plus:

<20 Weeks

>20 Weeks

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
  • 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 1-2mg/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

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

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. Osazuwa, Henry, and Michael Aziken. "Septic Abortion: A Review of Social and Demographic Characteristics." Archives of Gynecology and Obstetrics 275.2 (2007): 117-19.
  6. Gaufberg, Salva V., MD, and Pamela L. Dyne, MD. "Abortion Complications."Abortion Complications. Medscape, 22 Oct. 2012.