Septic abortion

Definition

According to the WHO, safe abortion is a procedure to terminate an unwanted pregnancy performed by a skilled provider in a setting meeting minimal medical standards. Unsafe abortions may result in infection and sepsis.

Septic abortion refers to uterine infection (endometritis) following:

1. Spontaneous abortion (miscarriage) or
2. Induced abortion:
   • Surgical
   • Unsafe (non-qualified attempts)
   • Rarely medical

Septic abortion is a true medical emergency. Delay in treatment significantly increases mortality risk.

Epidemiology

• Rare in developed nations due to legal abortion access
• Significant global health burden in areas with restricted access or unsafe practices

Legal Context

• In Australia, abortion is legal in all states
• Menhennitt ruling (1969): Abortion justified if necessary to protect a woman’s physical or mental health

Pathology

• Endometritis may spread to myometrium and beyond
• May progress to peritonitis, pelvic thrombophlebitis, septic shock, death

Polymicrobial organisms involved:

• Group A Streptococcus
• Staphylococci
• Anaerobes (including Clostridium)
• Gram-negative rods (Enterobacteriaceae)
• Less common: Chlamydia, Gonorrhoeae, Mycoplasma genitalium

WHO Classification of Abortion Safety

1. Safe: Appropriate method + trained provider
2. Less Safe: One criterion met (e.g. misoprostol use without guidance)
3. Least Safe: Dangerous methods by untrained providers (e.g. foreign body insertion)

Factors influencing safety:

• Availability of safe methods and trained providers
• Cost/access barriers
• Legal restrictions
• Stigma
• Health system development

Clinical Features

Septic abortion usually presents <1 week post-abortion/miscarriage, occasionally up to 6 weeks.

Symptoms/Signs:

• Fever ≥38°C
• Tachycardia, tachypnea
• Hypotension (if septic shock)
• Lower abdominal pain, uterine/fundal tenderness
• Vaginal bleeding
• Purulent vaginal discharge
• Signs of peritonitis (guarding, rigidity)
• Vaginal exam: cervical motion tenderness, retained POCs, cervical dilation/laceration

Investigations

Bloods:

• FBE (anaemia, leukocytosis)
• CRP
• U&Es, glucose
• Beta-HCG (to confirm recent pregnancy)
• Blood cultures (aerobic and anaerobic)
• Coags, VBG/lactate, crossmatch (if septic)

Swabs:

• Endocervical swabs for:
  • M/C/S
  • NAAT (PCR) for STI organisms: Chlamydia, Gonorrhoea, Mycoplasma

Imaging:

• Ultrasound: Assess for retained products, abscess, perforation

Note: A normal ultrasound does not exclude septic abortion

Management

1. Immediate Resuscitation:

• ABCs
• IV fluids
• Supportive care (e.g. inotropes, RRT, ventilation)

2. Analgesia

3. Empiric Antibiotics (prior to uterine evacuation):

• IV triple therapy:
  • Gentamycin/Ceftriaxone
  • Ampicillin
  • Metronidazole
• Single-agent alternative: Piperacillin-tazobactam

4. Uterine Evacuation:

• Urgent evacuation of necrotic/infected material
• Preferred: Vacuum or suction aspiration
• Avoid: Sharp curettage

5. Surgical Intervention (if indicated):

• Laparotomy or hysterectomy if:
  • No response to antibiotics + evacuation
  • Suspected perforation, bowel injury, abscess
  • Clostridial myometritis or necrotic uterus

6. Psychological and Social Support:

• Recognize social determinants and mental health risks
• Refer to:
  • Social work
  • Psychiatry (if adverse emotional reaction or prior mental illness)

Disposition

Urgent referrals to:

• Obstetrics and Gynaecology
• ICU (for sepsis/septic shock)
• Infectious Diseases
• Psychiatry and social work

Septic abortion is a critical emergency requiring rapid multidisciplinary intervention.

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References

FOAMed

• Quo M. Abnormal vaginal bleeding. CCC
• Hiller J, Yarwood L. Vaginal bleeding – nonpregnant. FFS
• Mackenzie J, Beech A. Procedure: Speculum examination. LITFL
• Hiller J, Yarwood L. Vaginal bleeding – nonpregnant. FFS
• Yarwood L, Hiller J. Vaginal bleeding – early pregnancy. FFS
• Hiller J, Yarwood L. Vaginal bleeding – miscarriage. FFS