Abortion, Septic Case File

Abortion, Septic Case File

Eugene C. Toy, MD, Patti Jayne Ross, MD, Benton Baker III, MD, John C. Jennings, MD

CASE 45

A 23-year-old woman underwent a dilation and curettage (D&C) for an incomplete abortion 3 days previously. She complains of continued vaginal bleeding and lower abdominal cramping. Over the last 24 hours, she notes significant fever and chills. On examination, her temperature is 102.5°F (39.2°C), blood pressure (BP) is 90/40 mm Hg, and heart rate (HR) is 120 beats per minute (bpm). The cardiac examination reveals tachycardia, and the lungs are clear. There is moderately severe lower abdominal tenderness. The pelvic examination shows the cervical os to be open to 1.5 cm, and there is uterine tenderness. The leukocyte count is 20,000/mm3, and the hemoglobin level is 12 g/dL. The urinalysis shows 2 wbc/hpf.

» What is the most likely diagnosis?

» What is the next step in management?

ANSWER TO CASE 45:

Abortion, Septic                                           

Summary: A 23-year-old woman, who had undergone a dilatation and curettage procedure 3 days ago for an incomplete abortion, complains of continued vaginal bleeding, lower abdominal cramping, and fever and chills. Her temperature is 102.5°F (39.2°C), BP is 90/ 40 mm Hg, and HR is 120 bpm. The lungs are clear. There is moderately severe lower abdominal tenderness. The cervix is open, and there is uterine tenderness. The laboratory studies are significant for leukocytosis and a normal urinalysis.

• Most likely diagnosis: Septic abortion (with retained products of conception).
• Next step in management: Broad-spectrum antibiotics and fluid resuscitation followed by D&C of the uterus.

ANALYSIS

Objectives

1. Understand the clinical presentation of septic abortion.
2. Know that the treatment of septic abortion involves antibiotic therapy and fluid resuscitation with uterine curettage.

Considerations

This 23-year-old woman underwent a D&C procedure for an incomplete abortion 3 days previously and now presents with lower abdominal cramping, vaginal bleeding, fever, and chills. The open cervical os, lower abdominal cramping, and vaginal bleeding suggest retained products of conception (POC). The retained POC may lead to ongoing bleeding or infection. In this case, the fever, chills, and leukocytosis point toward infection. The retained tissue serves as a nidus for infection. The most common source of the bacteria is the vagina, via an ascending infection. The best treatment is broad-spectrum antibiotics with anaerobic coverage and a uterine curettage. Usually, surgery is delayed until antimicrobial agents are infused for up to 4 hours to allow for tissue levels to increase. Hemorrhage may occur with the curettage procedure, since risk of perforation is high in an infected uterus. Also, the patient should be monitored for septic shock.

APPROACH TO:

Septic Abortion                                              

DEFINITIONS

SEPTIC ABORTION: Any type of abortion associated with a uterine infection.

SEPTIC SHOCK: The septic portion refers to the presence of an infection (usually bacterial), and the shock describes a process whereby the patient’s cells, organs, and/ or tissues are not being sufficiently supplied with nutrients and/ or oxygen.

CLINICAL APPROACH

The two most common complications associated with spontaneous abortion are hemorrhage and infection. Septic abortion occurs in 1% to 2% of all spontaneous abortions and about 0.5% of induced abortions. This risk is increased if an abortion is performed with nonsterile instrumentation. This condition is potentially fatal in 0.4 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 infection ascends from the vagina or cervix to the endometrium to myometrium to parametrium, and, eventually, the peritoneum. Affected women generally will have fever and leukocyte counts of > 10 500 cells/ μL. There is usually lower abdominal tenderness, cervical motion tenderness, and a foul-smelling vaginal discharge. The infection is almost always polymicrobial, involving anaerobic streptococci, bacteroidesspecies, Escherichia coli and other gram-negative rods, and group B β-hemolytic streptococci. Rarely, Clostridium perfringens, Hemophilusinfluenzae, and Campylobacter jejuni may be isolated.

    When patients present with signs and symptoms of septic abortion, a 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, and blood coagulability studies should be done. The blood pressure, oxygen saturation, heart rate, and urine output should be monitored.

    The treatment has four general parts: (1) maintain the blood pressure; (2) monitor the 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 β-lactam antimicrobials (cephalosporins and extended-spectrum penicillins) or those with β-lactamase inhibitors. Another regimen includes metronidazole plus ampicillin and an aminoglycoside. Because retained POC are common in these situations, becoming a nidus for infection to develop, evacuation of the uterine contents is important. Uterine curettage is usually performed approximately 4 hours after antibiotics are begun, allowing serum levels to be achieved. If patient does not respond to curettage and antibiotic treatment, a hysterectomy can be the next step in controlling the source of infection. Currently, no evidence has shown that a full antibiotic course is required if the patient remains afebrile for 48 hours post-D&C.

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

CASE CORRELATION See Case 42 (Spontaneous Abortion). Rarely, patients with spontaneous abortion with retained products of conception can develop a septic abortion.

COMPREHENSION QUESTIONS

45.1 A 34-year-old woman undergoes an elective termination of pregnancy at 12 weeks’ gestation. She develops fever, uterine tenderness, and is diagnosed with a septic abortion. Which of the following is the most likely mechanism of her infection?

A. Instrumental contamination

B. Ascending infection

C. Skin organisms

D. Urinary tract penetration

E. Hematogenous infection

45.2 A 22-year-old woman is diagnosed with a septic abortion after an incomplete abortion, fever, and uterine tenderness. She is treated with triple IV antibiotics and D&C of the uterus. After 48 hours of antibiotic therapy, she still has a fever of 102°F (38.8°C), BP of 80/ 40 mm Hg, and HR of 105 bpm.

A computed tomography (CT) scan of the abdomen and pelvis is performed revealing pockets of air within the muscle of the uterus. Which of the following is the best treatment for this patient?

A. Add extended anaerobic coverage to the antibiotic regimen

B. Add intravenous heparin to the regimen

C. Continue the present antibiotic therapy

D. Counsel the patient regarding need for hysterectomy

45.3 A 32-year-old G1P0 Hispanic female at 29 weeks’ gestation presents to the obstetrical triage unit complaining of fever, chills, and nausea and vomiting of 3 days duration. She also has myalgias. She denies leakage of fluid per vagina and states that she has been in good health. She has not been out of the country for 2 years. Questions about dietary habits reveal that she does not eat raw or uncooked foods, does not eat raw shellfish, but she does eat a fair amount of soft goat cheese. Her temperature is 101°F (38.33°C), BP is 100/ 80 mm Hg, and HR is 110 bpm. Her abdominal examination reveals tenderness of the uterine fundus. The fetal heart rate is 170 bpm. An ultrasound reveals a single gestation that is viable consistent with 29 weeks’ gestational age, and a normal amniotic fluid volume. An amniocentesis is performed revealing greenish dark fluid, and a Gram stain of the amniotic fluid shows gram-positive rods. Which of the following is the most likely diagnosis?

A. Group B streptococcus infection

B. Clostridial infection

C. Listeria monocytogenes infection

D. Pasteurellamultiforme infection

E. Meconium-stained amniotic fluid with bacterial skin contaminant

ANSWERS

45.1 B. Ascending infection is the most likely mechanism of septic abortion. The bacteria involved are typically polymicrobial, particularly anaerobes that have ascended from the lower genital tract. Signs and symptoms include uterine bleeding and/ or spotting in the first trimester with clinical signs of infection. There is usually lower abdominal tenderness, cervical motion tenderness, and a foul-smelling vaginal discharge. Also, careful attention should be given to the patient’s urine output since oliguria is an early sign of septic shock.

45.2 D. This patient has a septic abortion which has been treated conventionally with IV antibiotics and D&C to remove the nidus of the infection. She is still febrile and hypotensive despite antibiotic therapy for 48 hours. Also, due to the pockets of gas noted on CT scan, she likely has a necrotizing metritis, with gas-forming bacteria such as Clostridial species. Hysterectomy should be performed urgently as she may suffer severe morbidity or mortality if the procedure is delayed.

45.3 C. Chorioamnionitis, also called intra-amniotic infection, almost always complicates pregnancies with rupture of membranes. One exception to this rule is the Gram-positive rod Listeria monocytogenes, which can be acquired through unpasteurized milk products such as soft goat cheese. The bacterial infection in the maternal gastrointestinal tract, which presents as a flu-like illness, then is spread hematogenously to the fetus, through the placenta. The diagnosis is largely from clinical suspicion and confirmed by amniocentesis. Often the amniotic fluid is meconium stained, and Gram-positive rods may be seen on Gram stain. The microbiology laboratory should be alerted not to dismiss this finding as skin (bacteroid) contaminants. Treatment is with IV ampicillin. Many times, the infection may be treated with antibiotic therapy and avoid delivery (again, an exception to the usual rule of needing to deliver the baby in chorioamnionitis). Listeria can also cause miscarriage and septic abortion.

    CLINICAL PEARLS    

» The bacteria involved in septic abortion are usually polymicrobial, particularly anaerobes that have ascended from the lower genital tract. » Hemorrhage, due to uterine perforation, can often complicate the curettage for septic abortion. » Treatment of septic abortion consists of maintaining blood pressure; monitoring the blood pressure, oxygenation, and urine output; antibiotics; and uterine evacuation of infected tissue.

REFERENCES

Eschenbach, DA. Treating spontaneous and induced septic abortions. Obstet Gynecol. 2015;125: 1042-1048. 

Euhus DM. First-trimester abortion. In: Hoffman B, Schorge J, Schaffer J, H alvorson L, Bradshaw K, Cunningham F, eds. Williams Gynecology. 2nd ed. New York, NY: McGraw-Hill; 2012. 

Katz VL. Spontaneous and recurrent abortion. In: Katz VL, Lentz GM, Lobo RA, Gersenson DM, eds. Comprehensive Gynecology. 6th ed. St. Louis, MO: Mosby-Year Book; 2012:359-387.

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