Septic abortion

Septic abortion typically refers to pregnancies of < 20 weeks gestation while those ≥ 20 weeks gestation with intrauterine infection are usually described as having intra-amniotic infection.

Septic abortion is an infection of the uterus (endometritis) following either:

1. Spontaneous abortion (miscarriage)
2. Induced abortion
   • Surgical
   • Unsafe (i.e non-qualified surgical attempts)
   • Medical abortion (rarely).

Infection may spread, causing bacteraemia, peritonitis with septic shock and death.

Septic abortion is a true medical emergency.

Delay in treatment is one of the leading causes of death after septic abortion.

Although unsafe abortion and its attendant high risk for sepsis is now rare in developed countries, it remains a significant health issue on the global scale.  

History

A landmark legal precedent concerning the legality of abortion was set in Australia in 1969, by the Menhennitt ruling in the Victorian Supreme Court case R v Davidson.

This held that abortion was lawfully justified if “necessary to preserve the physical or mental health of the woman concerned, provided that the danger involved in the abortion did not outweigh the danger which the abortion was designed to prevent”.

Today abortion is legal in all states of Australia. As for elsewhere in the world, the incidence of septic abortion including death from septic shock, has declined dramatically, following the de-criminalization of abortion.

However, morbidity and mortality from unsafe abortions and subsequent sepsis remain a serious health problem on the global scale.

Epidemiology

Although unsafe abortion and its attendant high risk for sepsis is now rare in developed countries, it remains a significant health issue on the global scale. 

Pathology

Endometritis may extend into the myometrium and parametrium, and progress beyond the uterus, causing peritonitis, pelvic thrombophlebitis, septic shock and death.

Organisms:

Septic abortion is usually a polymicrobial infection.

These can include:

• Streptococcus pyogenes (group A streptococcus).
• Staphylococci
• Anaerobic bacteria.
• Clostridium species
• Gram negative species; predominantly Enterobacteriaceae / enterococci.

Less commonly:

• Chlamydia trachomatis
• Neisseria gonorrhoeae
• Mycoplasma genitalium

Patients who are critically ill with sepsis or septic shock may have infection caused by Clostridium species or Streptococcus pyogenes (group A streptococcus).

Risk Assessment

Sexually transmitted infections, including gonorrhoea, Chlamydia trachomatis, and trichomoniasis, are less commonly risk factors for uterine infection and septic abortion.

Current WHO definitions conceptualise abortion safety as falling into three categories:

Safe: satisfying two criteria

• If performed using a method recommended by WHO (medical abortion, vacuum aspiration, or dilatation and evacuation) appropriate to the pregnancy duration
• If the person providing the abortion is appropriately trained.

Less safe, where only one of the two above criteria are met

• The abortion is done by a trained provider but with an outdated method (e.g., sharp curettage)
• A safe method of abortion (e.g., misoprostol) is used but without adequate information or support from a trained individual.

Least safe

• Abortions are least safe if they are provided by untrained individuals using dangerous methods, such as ingestion of caustic substances, insertion of foreign bodies, or use of traditional concoctions.

The less-safe and least-safe categories together reflect the spectrum of unsafe abortions.

Factors affecting abortion safety at a country level include:

• The abortion service-delivery environment: This encompasses the availability of safe methods, trained providers, and   facilities equipped to provide safe abortion.
• Financial access to services: a woman’s ability to pay for safe abortion services within or outside her country of residence.
• Abortion stigma: attitudes toward abortion and is associated with gender inequality regarding women’s empowerment, autonomy, and agency
• Legal context: the legal grounds for abortion, associated laws and policies, and their interpretation and implementation.
• Development of health services: includes the overall development level of health services and health    infrastructure.

Clinical features

Septic abortion is a clinical diagnosis made in patients who present with signs and symptoms of uterine infection (uterine pain and tenderness, fever, vaginal bleeding) following pregnancy loss or termination up to 20 weeks gestation.

• The majority of cases present within the first week after delivery.
• Around 15% of cases present between 1 – 6 weeks postpartum.
• Later presentations are often less severe and may present as late postpartum haemorrhage.
• Infection may remain localized but can become systemic with resulting life-threatening septic shock.     

Clinical presentation is variable depending on how septic patients are. Septic abortion can present insidiously as a chronic pelvic infection or as acutely as peritonitis.

Clinical features include:

• Vital signs
  • Fever (38°C or more)
  • Tachycardia
  • Tachypnea
  • Hypotension if septic / critically unwell
• Abdominal pain / tenderness
• Vaginal bleeding
• Purulent vaginal discharge may be present
• Signs of frank peritonitis, when there has been spread to the peritoneum:
  • Abdominal guarding
  • Abdominal rigidity
• Vaginal examination may reveal:
  • Purulent discharge
  • Vaginal or cervical lacerations from instrumentation
  • Cervical dilation
  • Products of conception
  • Cervical motion tenderness
  • Uterine/ fundal tenderness.

Investigations

Blood tests:

1. FBE
   • Anemia
   • Leukocytosis
2. CRP
3. U&E/ glucose
4. Blood cultures, (both aerobic and anaerobic).
5. Beta-HCG:
   • If the beta-HCG is still elevated or somewhat elevated then this suspicion would be supported.   
   • Additionally patients presenting with infection in the setting of pregnancy loss may not be aware that they are or have recently been pregnant
6. Blood grouping.
   For unwell septic patients:
7. Coagulation studies
8. VBGs/ lactate
9. Blood cross match

Swabs for microscopy and culture:

Endocervical swabs for:

1. Microscopy, culture, and antibiotic sensitivity testing.
2. Nucleic acid amplification testing (NAAT) e.g. polymerase chain reaction (PCR).

Test for STI organisms:

• Chlamydia trachomatis
• Neisseria gonorrhoeae
• Mycoplasma genitalium

Ultrasound

A pelvic ultrasound may be helpful to exclude the presence of retained products of conception or a tubo-ovarian abscess.

While ultrasound can be useful to confirm pregnancy loss and evaluate the uterus, the decision to treat with antibiotics and evacuate the uterus is based on the patient’s history and evaluation findings. Ultrasound cannot definitively diagnose, septic abortion.  

While ultrasound can assist in the diagnosis by demonstrating retained products of conception, but normal ultrasound imaging does not exclude the possibility of septic abortion.

Management

Septic abortion is a true medical emergency.

Delay in treatment is one of the leading causes of death after septic abortion.

1. Immediate attention to any ABC issues
   • IV fluid resuscitation as required.
   • Supportive treatments as required  
     • Inotropes
     • Renal replacement therapy
     • Mechanical ventilation
2. Analgesia as required
3. Antibiotics:
   • Patients who are critically ill may have infection caused by Streptococcus pyogenes or Clostridium species and broad spectrum antibiotics must be initiated urgently.  
   • A suitable IV triple therapy regime includes:
     • Gentamycin / Ceftriaxone
     • Ampicillin
     • Metronidazole
   • Piperacillin-tazobactam provides the greatest single-agent microbial coverage.
   • It is important to initiate antibiotics before uterine evacuation, given the potential for hematologic bacterial seeding during the procedure and exacerbation of sepsis.
4. Surgical:
   • Uterine evacuation:
     • Evacuation of necrotic and infected material from the uterus is critical to the treatment of a patient with septic abortion, and should be done on an urgent basis.
     • Vacuum or suction aspiration is the preferred technique.
     • Sharp curettage is contraindicated in septic abortions.  
   • Laparotomy:
     • Indications for laparotomy and hysterectomy include:
       • Patients who have received adequate treatment with antibiotics and uterine evacuation without clinical response.
       • Suspected uterine perforation including bowel injury / pelvic abscess
       • Suspected clostridial myometritis
     • A hysterectomy should be performed in the case of a necrotic or woody-appearing uterus, signs of gas in the pelvic tissue (either on imaging or with crepitus), or uncontrolled bleeding from the uterus.
5. Psychological support:
   • Unwanted pregnancy and abortion are affected by the complex social and cultural environments in which women may live on a daily basis.
   • Unwanted pregnancy can be associated with correlated with conditions such as poverty, exposure to violence, and drug use, all of which can affect mental health.
   • Prior mental health status and the presence or absence of social supports are strong predictors of mental health post-abortion.
   • Additionally , women who experience adverse abortion events such as septic abortion may be at additional risk for emotional distress.
   • Recognition of possible risk factors should prompt involvement of social work support services and/ or psychiatric services.

Disposition

Septic abortion isa true medical emergency

The should be immediate referral to the Obstetrics and Gynaecology Unit.

Referral to the following may also be required:

• ICU
• Infectious Diseases / microbiology laboratory
• Psychiatry
• Social work

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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

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