Septic abortion: Difference between revisions

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**[[Clostridium]] perfringens is associated with a higher mortality
**[[Clostridium]] perfringens is associated with a higher mortality
**[[Tetanus]], especially in developing nations and if nonsterile instrumentation is the cause
**[[Tetanus]], especially in developing nations and if nonsterile instrumentation is the cause
===Risk Factors===
===Risk Factors===
*Non Sterile abortions
*Non Sterile abortions
*Advanced gestational age
*Advanced gestational age
===Epidemiology===
===Epidemiology===
*Huge cause of maternal mortality worldwide
*Huge cause of maternal mortality worldwide
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*Overall mortality: 20-50%
*Overall mortality: 20-50%
*Mortality rare in US (1 in 100,000 abortions)
*Mortality rare in US (1 in 100,000 abortions)
==Clinical Features==
==Clinical Features==
*Abdominal or pelvic pain
*Abdominal or pelvic pain
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*History of recent pregnancy or known induced or spontaneous abortion  
*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==
 
==Differential Diagnosis==
===[[Abdominal Pain in Pregnancy]]===
{{Abdominal Pain Pregnancy DDX}}
 
===[[Vaginal Bleeding]]===
{{VB DDX greater than 20}}
 
==Workup==
*Clinical diagnosis; patient may be reluctant to share information that she had an unsafe abortion
*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
*Labs: CBC, blood type with Rh status, CMP, serum beta-hcg level, UA, blood cultures
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*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<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>
*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>
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*Early OB consult – Most will need evacuation of any remaining products of conception
*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
*Early surgery consult - Exploratory laparotomy if any pelvic free fluid or intra-abdominal air
==Disposition==
Admit
==Complications==
==Complications==
*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>
*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>
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*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]]
*[[First Trimester Abortion]]

Revision as of 18:58, 12 September 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)
    • 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

Abdominal Pain in Pregnancy

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

<20 Weeks

>20 Weeks

Any time

Vaginal Bleeding

Vaginal Bleeding in Pregnancy (>20wks)

Workup

  • 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

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

Sources

  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.
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