Clinical Approach

Septic abortion occurs in approximately 1% of all spontaneous abortions and approximately 0.5% of induced abortions. This risk is increased if an abortion is performed with nonsterile instrumentation. This condition is fatal in 0.4:1000,000 to 0.6:100.000 spontaneous abortions.

Signs and symptoms of septic abortion are uterine bleeding and/or spotting in the first trimester with clinical signs of infection. The mechanism is ascending infection from the vagina or cervix to the endometrium to myometrium to parametrium, and. eventually, the peritoneum. Affected women generally have fever and leukocyte counts greater than 10.500 cells/^L. There is usually lower abdominal tenderness, cervical motion tenderness, and a foul-smelling vaginal discharge. The infection almost always is polymicrobial, involving anaerobic streptococci. Bacteroides species, Escherichia coli and other gram-negative rods, and group B fi-hemolytic streptococci. Rarely, Clostridium perfringens, Haemophilus influenzae, and Campylobacter jejuni are isolated.

When patients present with signs and symptoms of septic abortion, a complete blood count (CBC) with differential, urinalysis, and blood chemistries including electrolytes should be obtained. A specimen of cervical discharge should be sent for Gram stain, as well as for culture and sensitivity. If the patient appears seriously ill or is hypotensive, blood cultures, a chest x-ray film, and blood coagulability studies should be done. Blood pressure, oxygen saturation, heart rate, and urine output should he monitored.

The treatment has four general parts: 1) maintain the blood pressure; 2) monitor blood pressure, oxygenation, and urine output; 3) start antibiotic therapy; and 4) perform a uterine curettage. Immediate therapeutic steps include intravenous isotonic fluid replacement, especially in the face of hypotension. Concurrently, intravenous broad-spectrum antibiotics with particular attention to anaerobic coverage should be infused. The combination of gentamicin and clindamycin has a favorable response 95% of the time. Alternatives include (i-lactam antimicrobials (cephalosporins and extended-spectrum penicillins) or those with p-lactaniase inhibitors. Another regimen includes metronidazole plus ampicillin and an aminoglycoside. Because retained POC are common in these situations and become a nidus for development of infection, evacuation of the uterine contents is important. Uterine curettage usually is performed approximately 4 hr after antibiotics are started, allowing serum levels to be achieved.

Because oliguria is an early sign of septic shock, urine output should be carefully observed. Also, a central venous pressure catheter may be warranted for women in shock. Aggressive intravenous fluids usually are effective in maintaining the blood pressure; however, at times, vasopressor agents, such as a dopamine infusion, may be required. Other therapies include oxygen, digitalis, and steroids.

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