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)
  • Leading to PID and peritonitis then 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 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
• 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 pain differential as non-pregnant patients, plus:

<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

Any time

• Hemorrhagic ovarian cyst
• Fibroid degeneration or torsion
• Ovarian torsion
• Constipation

Vaginal Bleeding in Pregnancy (>20wks)

• Emergent delivery
• Placental abruption
• Placenta previa
• Vasa previa
• Uterine rupture
• Preterm labor
• Vaginal trauma
• Placenta accreta
• Intrauterine fetal demise

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
• 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
• 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)