Septic abortion
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
<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
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.
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