eMedicine Specialties > Emergency Medicine > Obstetrics & Gynecology

Abortion, Septic

Slava V Gaufberg, MD, Assistant Professor of Medicine, Harvard Medical School; Director of Transitional Residency Training Program, Cambridge Health Alliance

Updated: Dec 17, 2008

Introduction

Background

A septic abortion is a spontaneous or therapeutic/artificial abortion complicated by a pelvic infection.

Pathophysiology

Infection usually begins as endometritis and involves the endometrium and any retained products of conception. If not treated, the infection may spread further into the myometrium and parametrium. Parametritis may progress into peritonitis. The patient may develop bacteremia and sepsis at any stage of septic abortion. Pelvic inflammatory disease (PID) is the most common complication of septic abortion.

Mortality/Morbidity

Septic abortion was once the leading cause of maternal death around the world. The condition remains a primary cause of maternal mortality in the developing world, mostly as a result of illegal abortions.
In the US, mortality from septic abortion rapidly declined after legalization of abortion. Death now occurs in less than 1 per 100,000 abortions. Figures for most European countries are similar to US rates.
The risk of death from septic abortion rises with the progression of gestation.

Clinical

History

Any woman of childbearing age presenting with fever, abdominal pain, vaginal discharge, or vaginal bleeding should be evaluated for a possible septic abortion.
Patients with septic abortion usually present with complaints including the following:
- Fever
- Abdominal pain
- Vaginal discharge
- Vaginal bleeding
- History of recent pregnancy

Physical

Perform an abdominal examination with attention to guarding, rebound tenderness, and bowel sounds.
Perform a pelvic examination to assess vaginal discharge, bleeding, cervical motion tenderness, uterine and adnexal tenderness, and masses.

Causes

Two major factors contribute to development of septic abortion.

Retained products of conception due to incomplete spontaneous or therapeutic abortion
Introduction of infection into the uterus. Pathogens causing septic abortion usually are mixed and derived from normal vaginal flora and sexually transmitted bacteria. These organisms include the following:
- Escherichia coli and other aerobic, enteric, gram-negative rods
- Group B beta-hemolytic streptococci
- Staphylococcal organisms
- Bacteroides species
- Neisseria gonorrhoeae
- Chlamydia trachomatis
- Clostridium perfringens
- Mycoplasma hominis
- Haemophilus influenzae

Differential Diagnoses

Appendicitis, Acute	Shock, Septic
Pelvic Inflammatory Disease	Urinary Tract Infection, Female
Pregnancy, Ectopic	Vaginitis
Pregnancy, Trauma	Vulvovaginitis
Pregnancy, Urinary Tract Infections

Workup

Laboratory Studies

Complete blood count
Erythrocyte sedimentation rate
Beta-human chorionic gonadotropin; quantitative levels may provide a basis for future comparison
Electrolytes, glucose, BUN, and creatinine
Blood type and screen
Endocervical cultures (eg, aerobic, anaerobic, gonorrheal, chlamydial) and Gram stain
Blood cultures

Imaging Studies

Perform an ultrasound examination to identify retained products of conception in the uterus, adnexal masses, and free fluid in the cul-de-sac.
Both supine and upright radiographs of the abdomen assist in detection of free air or foreign bodies. Perform an exploratory laparotomy if a large amount of free air under the diaphragm is accompanied by fever, chills, vaginal bleeding, and abdominal pain.

Treatment

Prehospital Care

Prehospital care for patients with suspected septic abortion include the following:

Monitor vital signs.
Stabilize with IV fluids (eg, normal saline, Ringer lactate).
Administer oxygen.

Emergency Department Care

ED care for patients with suspected septic abortion include the following:

Administer IV fluids through a large-bore angiocatheter.
For patients who are unstable, administer oxygen and insert a Foley catheter.
Early antibiotic treatment may be guided by Gram stain, but broad-spectrum coverage is recommended.
Perform evacuation of retained tissues from the uterine cavity, preferably by dilation and curettage (D&C). If D&C is not immediately available, high doses of oxytocin can be used.
Laparotomy may be needed if the above measures elicit no response.
A hysterectomy may be necessary in cases of uterine perforation, bowel injury, clostridial myometritis, and pelvic abscess.
Management of septic shock is discussed in Shock, Septic.

Consultations

Consult obstetrics and gynecology (OB/GYN) as soon as possible.

Medication

Aggressive antimicrobial therapy prevents death by eliminating all septic sources during the early stages of the disease.

Antibiotics

Therapy must cover all likely pathogens in the context of the clinical setting. Once sensitivities are known, the use of antibiotic monotherapy is recommended.

Doxycycline (Bio-Tab, Doryx, Vibramycin)

Used for treatment of infections caused by susceptible gram-negative and gram-positive organisms, in addition to infections caused by susceptible Rickettsia, Chlamydia, and Mycoplasma species.

Dosing

Adult

100 mg doxycycline IV q12h with 2 g cefoxitin IV qid; administer for at least 4 d and for at least 48 h after patient improves; PO doxycycline (100 mg) should then be administered bid for a total of 10-14 d

Pediatric

<12 years: Not established
>12 years: 2-5 mg/kg/d in 1-2 divided doses; not to exceed 200 mg/d

Interactions

Bioavailability decreases with antacids containing Al, Ca, Mg, Fe, or Bi subsalicylate; tetracyclines can increase hypoprothrombinemic effects of anticoagulants; tetracyclines can decrease effects of PO contraceptives, causing breakthrough bleeding and increased risk of pregnancy

Contraindications

Documented hypersensitivity; severe hepatic dysfunction

Precautions

Pregnancy

D - Fetal risk shown in humans; use only if benefits outweigh risk to fetus

Precautions

Photosensitivity may occur with prolonged exposure to sunlight or tanning equipment; reduce dose in renal impairment; consider drug serum level determinations in prolonged therapy; tetracycline use during tooth development (last one half of pregnancy through age 8 y) can cause permanent discoloration of teeth; Fanconilike syndrome may occur with outdated tetracyclines

Cefoxitin (Mefoxin)

Second-generation cephalosporin indicated for the management of infections caused by susceptible gram-positive cocci and gram-negative rods. Many infections caused by gram-negative bacteria that are resistant to some cephalosporins and penicillins respond to cefoxitin.

Dosing

Adult

2 g cefoxitin IV q6h with 100 mg doxycycline q12h; administer for at least 4 d and for at least 48 h after patient improves
Alternatively, 100 mg PO bid for 10-14 d

Pediatric

<12 years: Not established
>12 years: 80-160 mg/kg/d divided q4-6h; increase dose for more severe or serious infections; not to exceed 12 g/d

Interactions

Probenecid may increase effects of cefoxitin; coadministration with aminoglycosides or furosemide may increase nephrotoxicity (closely monitor renal function)

Contraindications

Documented hypersensitivity

Precautions

Pregnancy

B - Fetal risk not confirmed in studies in humans but has been shown in some studies in animals

Precautions

Bacterial or fungal overgrowth of nonsusceptible organisms may occur with prolonged use or repeated treatment; caution in patients with previously diagnosed colitis

Gentamicin (Gentacidin, Garamycin)

Aminoglycoside antibiotic for gram-negative coverage. Used in combination with both an agent against gram-positive organisms and one that covers anaerobes.
Not DOC. Consider if penicillins or other less toxic drugs are contraindicated, when clinically indicated, and in mixed infections caused by susceptible staphylococci and gram-negative organisms.
Dosing regimens are numerous; adjust dose based on CrCl and changes in volume of distribution. May be given IV/IM.

Dosing

Adult

Serious infections and normal renal function: 3 mg/kg/d IV/IM q8h
Life-threatening infections: 5 mg/kg/d IV/IM q6-8h
Loading dose: 1-2.5 mg/kg IV q8h
Maintenance dose: 1-1.5 mg/kg IV q8h

Pediatric

<12 years: Not established
>12 years: 1.5-2.5 mg/kg/dose IV/IM q8h or 6-7.5 mg/kg/d IV/IM divided q8h
Not to exceed 300 mg/d with adjustments for renal function prn

Interactions

Coadministration with other aminoglycosides, cephalosporins, penicillins, and amphotericin B may increase nephrotoxicity; aminoglycosides enhance effects of neuromuscular blocking agents; thus prolonged respiratory depression may occur
Coadministration with loop diuretics may increase auditory toxicity of aminoglycosides; possible irreversible hearing loss of varying degrees may occur (monitor regularly)

Contraindications

Documented hypersensitivity; non–dialysis-dependent renal insufficiency

Precautions

Pregnancy

C - Fetal risk revealed in studies in animals but not established or not studied in humans; may use if benefits outweigh risk to fetus

Precautions

Narrow therapeutic index (not intended for long-term therapy); caution in renal failure (not on dialysis), myasthenia gravis, hypocalcemia, and conditions that depress neuromuscular transmission; adjust dose in renal impairment

Ticarcillin and clavulanate potassium (Timentin)

Used as presumptive therapy prior to identification of organisms. Inhibits biosynthesis of cell wall mucopeptide and is effective during stage of active growth.

Dosing

Adult

<60 kg: 200-300 mg/kg/d IV divided q4-6h
>60 kg: 3.1 g IV q4-6h; not to exceed 18-24 g/d

Pediatric

Administer as in adults

Interactions

Tetracyclines may decrease effects of ticarcillin; high concentrations of ticarcillin may physically inactivate aminoglycosides if administered in same IV line; effects when administered concurrent with aminoglycosides are synergistic; probenecid may increase penicillin levels

Contraindications

Documented hypersensitivity; severe pneumonia, bacteremia, pericarditis, emphysema, meningitis, and purulent or septic arthritis should not be treated with PO penicillin during acute stage

Precautions

Pregnancy

B - Fetal risk not confirmed in studies in humans but has been shown in some studies in animals

Precautions

Perform CBCs prior to initiation of therapy and at least weekly during therapy; monitor for liver function abnormalities by measuring AST and ALT during therapy; exercise caution in patients diagnosed with hepatic insufficiencies; perform UA, BUN, and creatinine determinations during therapy and adjust dose if values become elevated; monitor blood levels to avoid possible neurotoxic reactions

Imipenem and cilastatin (Primaxin)

For treatment of multiple organism infections in which other agents do not have wide-spectrum coverage or are contraindicated due to potential for toxicity.
Initial dose should be based on severity of infection and should be administered in equally divided doses.

Dosing

Adult

250-500 mg IV q6h; not to exceed 3-4 g/d
Alternatively, administer 500-750 mg IM/intra-abdominally q12h

Pediatric

<12 years: Do not administer
>12 years: 10-25 mg/kg/dose IV q6h
Fully susceptible organisms: Not to exceed 2 g/d
Moderately susceptible organisms: Not to exceed 4 g/d

Interactions

Coadministration with cyclosporine may increase CNS adverse effects of both agents; coadministration with ganciclovir may result in generalized seizures

Contraindications

Documented hypersensitivity

Precautions

Pregnancy

C - Fetal risk revealed in studies in animals but not established or not studied in humans; may use if benefits outweigh risk to fetus

Precautions

Adjust dose in renal insufficiency

Ampicillin and sulbactam (Unasyn)

Drug combination of beta-lactamase inhibitor with ampicillin. Covers skin, enteric flora, and anaerobes. Not ideal for nosocomial pathogens.

Dosing

Adult

1.5 (1 g ampicillin + 0.5 g sulbactam) to 3 g (2 g ampicillin + 1 g sulbactam) IV/IM q6-8h; not to exceed 4 g/d sulbactam or 8 g/d ampicillin

Pediatric

<3 months: Not established
3 months to 12 years: 100-200 mg ampicillin/kg/d (150-300 mg Unasyn) IV divided q6h
>12 years: Administer as in adults

Interactions

Probenecid and disulfiram elevate ampicillin levels; allopurinol decreases ampicillin effects and has additive effects on ampicillin rash; may decrease effects of PO contraceptives

Contraindications

Documented hypersensitivity

Precautions

Pregnancy

B - Fetal risk not confirmed in studies in humans but has been shown in some studies in animals

Precautions

Adjust dose in renal failure; evaluate rash and differentiate from hypersensitivity reaction

Piperacillin and Tazobactam sodium (Zosyn)

Antipseudomonal penicillin plus beta-lactamase inhibitor. Inhibits biosynthesis of cell wall mucopeptide and is effective during stage of active multiplication.

Dosing

Adult

3/0.375 g (piperacillin 3 g and tazobactam 0.375 g) IV q6h for 7-10 d

Pediatric

<12 years: Not established
>12 years: Administer as in adults

Interactions

Contraindications

Documented hypersensitivity

Precautions

Pregnancy

B - Fetal risk not confirmed in studies in humans but has been shown in some studies in animals

Precautions

Clindamycin (Cleocin)

Lincosamide for treatment of serious skin and soft tissue staphylococcal infections. Also effective against aerobic and anaerobic streptococci (except enterococci). Inhibits bacterial growth, possibly by blocking dissociation of peptidyl tRNA from ribosomes causing RNA-dependent protein synthesis to arrest.

Dosing

Adult

600-1200 mg/d IV/IM divided q6-8h depending on degree of infection

Pediatric

20-40 mg/kg/d IV/IM divided tid/qid
Severe infections: May increase dose to 16-20 mg/kg/d IV/IM divided tid/qid

Interactions

Increases duration of neuromuscular blockade induced by tubocurarine and pancuronium; erythromycin may antagonize effects of clindamycin; antidiarrheals may delay absorption of clindamycin

Contraindications

Documented hypersensitivity; regional enteritis; ulcerative colitis; hepatic impairment; antibiotic-associated colitis

Precautions

Pregnancy

B - Fetal risk not confirmed in studies in humans but has been shown in some studies in animals

Precautions

Adjust dose in severe hepatic dysfunction; no adjustment necessary in renal insufficiency; associated with severe and possibly fatal colitis

Cefotaxime (Claforan)

For septicemia and treatment of gynecologic infections caused by susceptible organisms. Arrests bacterial cell wall synthesis, which in turn inhibits bacterial growth.

Dosing

Adult

Moderate to severe infections: 1-2 g IV/IM q6-8h
Life-threatening infections: 1-2 g IV/IM q4h

Pediatric

<12 years: Not established
>12 years: Administer as in adults

Interactions

Probenecid may increase cefotaxime levels; coadministration with furosemide and aminoglycosides may increase nephrotoxicity

Contraindications

Documented hypersensitivity

Precautions

Pregnancy

B - Fetal risk not confirmed in studies in humans but has been shown in some studies in animals

Precautions

Adjust dose in severe renal impairment; has been associated with severe colitis

Ceftriaxone (Rocephin)

Third-generation cephalosporin with broad-spectrum gram-negative activity; lower efficacy against gram-positive organisms; higher efficacy against resistant organisms. Arrests bacterial growth by binding to one or more penicillin-binding proteins.

Dosing

Adult

1-2 g IV qd or divided bid depending on type and severity of the infection; not to exceed 4 g/d

Pediatric

<12 years: Not established
>12 years: 50-75 mg/kg/d IV divided q12h; not to exceed 2 g/d

Interactions

Probenecid may increase ceftriaxone levels; coadministration with ethacrynic acid, furosemide, and aminoglycosides may increase nephrotoxicity

Contraindications

Documented hypersensitivity

Precautions

Pregnancy

B - Fetal risk not confirmed in studies in humans but has been shown in some studies in animals

Precautions

Adjust dose in renal impairment; caution in breastfeeding women and allergy to penicillin

Synthetic posterior pituitary hormones

When D&C is not immediately available, these hormones are used to induce contractions to help evacuate retained products of conception from the uterus.

Oxytocin (Pitocin, Syntocinon)

Produces rhythmic uterine contractions and can stimulate the gravid uterus, as well as vasopressive and antidiuretic effects. Also can control postpartum bleeding or hemorrhage.

Dosing

Adult

10-40 U IV in 1000 mL of IV fluid at a rate to control uterine atony

Pediatric

<12 years: Not established
>12 years: Administer as in adults

Interactions

Pressor effect of sympathomimetics may increase when used concomitantly with oxytocic drugs, causing postpartum hypertension

Contraindications

Documented hypersensitivity; pregnant patients with severe toxemia, unfavorable fetal positions, and a contracting uterus with hypertonic or hyperactive patterns; labor in which vaginal delivery should be avoided (eg, invasive cervical carcinoma, cord presentation or prolapse, active herpes genitalis, total placenta previa, and vasa previa)

Precautions

Pregnancy

X - Contraindicated; benefit does not outweigh risk

Precautions

A uterus that is overstimulated can be hazardous to both mother and fetus; hypertonic contractions can occur in a patient whose uterus is hypersensitive to oxytocin, regardless of whether oxytocin was administered appropriately; has intrinsic antidiuretic effect that when administered by continuous infusion and patient is receiving PO fluids, can cause water intoxication

Follow-up

Further Inpatient Care

Further inpatient care for patients with septic abortion include the following:

Perform a prompt evacuation of retained products of conception from the uterus.
Administer aggressive antibiotic therapy.
Monitor temperature, vaginal discharge, and bleeding.

Deterrence/Prevention

Deterrence and prevention of septic abortion include the following:

Contraception to prevent unwanted pregnancies
Safe and legal abortions
Easy access to prenatal care
Prompt diagnosis of septic abortion
Timely treatment with IV antibiotics
Prompt evacuation of retained tissue from the uterus

Complications

Complications of septic abortion may include the following:

Pelvic inflammatory disease
Peritonitis
Hemorrhage
Sepsis
Septic shock
Inferior vena cava thrombosis

Patient Education

For excellent patient education resources, visit eMedicine's Pregnancy and Reproduction Center and Procedures Center. Also, see eMedicine's patient education articles Miscarriage, Abortion, and Dilation and Curettage (D&C).

Miscellaneous

Medicolegal Pitfalls

Failure to obtain information about recent termination of pregnancy may lead to a wrong diagnosis or delayed/inappropriate treatment.
Failure to promptly administer broad-spectrum antibiotic therapy may result in complications, including sepsis and septic shock.
Failure to evacuate retained products of conception from the uterus leads to treatment failure and possible complications.
Failure to diagnose uterine perforation may lead to life-threatening complications.
Failure to diagnose bowel injury may lead to life-threatening complications.

References

Cates W, Rochat RW, Grimes DA, Tyler CW Jr. Legalized abortion: effect on national trends of maternal and abortion-related mortality (1940 through 1976). Am J Obstet Gynecol. Sep 15 1978;132(2):211-4. [Medline].
Chatterjee C, Joardar GK, Mukherjee G, Chakraborty M. Septic abortions: a descriptive study in a teaching hospital at North Bengal, Darjeeling. Indian J Public Health. Jul-Sep 2007;51(3):193-4:[Medline].
CherpesTL, Kusne S, Hillier SL. Haemophilus influenzae septic abortion. Infec Dis Obstet Gynecol. 2002;10(3):161-4. [Medline].
Finkielman JD, De Feo FD, Heller PG, Afessa B. The clinical course of patients with septic abortion admitted to an intensive care unit. Intensive Care Med. Jun 2004;30(6):1097-102. [Medline].
Jewett JF. Septic induced abortion. N Engl J Med. Oct 4 1973;289(14):748-9. [Medline].
Kollef MH, Schuster DP. The acute respiratory distress syndrome. N Engl J Med. Jan 5 1995;332(1):27-37. [Medline].
Osazuwa H, Aziken M. Septic abortion: a review of social and demographic characteristics. Arch Gynecol Obstet. Feb 2007;275(2):117-9:[Medline].
Rana A, Pradhan N, Gurung G, Singh M. Induced septic abortion: a major factor in maternal mortality and morbidity. J Obstet Gynaecol Res. Feb 2004;30(1):3-8. [Medline].
Rochelson B, Scher L, Warshawsky R, Simon D. Use of a temporary vena cava filter in a woman with septic abortion and inferior vena cava thrombosis. A case report. J Reprod Med. Jul 2003;48(7):557-9. [Medline].
Scott JR. Early pregnancy loss (septic abortion). In: Danforth's Obstetric and Gynecology. Lippincott-Raven Publishers; 1994:179.
Soper DE. Abortion and clostridial toxic shock syndrome. Obstet Gynecol. Nov 2007;110(5):970-1:[Medline].
Stevenson MM, Radcliffe KW. Preventing pelvic infection after abortion. Int J STD AIDS. Sep-Oct 1995;6(5):305-12. [Medline].
Stubblefield PG, Grimes DA. Septic abortion. N Engl J Med. Aug 4 1994;331(5):310-4. [Medline].

Keywords

septic abortion, miscarriage, spontaneous abortion, therapeutic abortion, artificial abortion, pelvic infection, pelvic inflammatory disease, PID

Contributor Information and Disclosures

Author

Slava V Gaufberg, MD, Assistant Professor of Medicine, Harvard Medical School; Director of Transitional Residency Training Program, Cambridge Health Alliance
Slava V Gaufberg, MD is a member of the following medical societies: American College of Emergency Physicians
Disclosure: Nothing to disclose.

Medical Editor

Roy Alson, MD, PhD, FACEP, FAAEM, Associate Professor, Department of Emergency Medicine, Wake Forest University School of Medicine; Medical Director, Forsyth County EMS; Deputy Medical Advisor, North Carolina Office of EMS; Associate Medical Director, North Carolina Baptist AirCare
Roy Alson, MD, PhD, FACEP, FAAEM is a member of the following medical societies: American College of Emergency Physicians, American Medical Association, National Association of EMS Physicians, North Carolina Medical Society, Society for Academic Emergency Medicine, and Wilderness Medical Society
Disclosure: Nothing to disclose.

Pharmacy Editor

Francisco Talavera, PharmD, PhD, Senior Pharmacy Editor, eMedicine
Disclosure: Nothing to disclose.

Managing Editor

Mark Zwanger, MD, MBA, Assistant Professor, Department of Emergency Medicine, Thomas Jefferson University
Mark Zwanger, MD, MBA is a member of the following medical societies: American Academy of Emergency Medicine, American College of Emergency Physicians, and American Medical Association
Disclosure: Nothing to disclose.

CME Editor

John D Halamka, MD, MS, Associate Professor of Medicine, Harvard Medical School, Beth Israel Deaconess Medical Center; Chief Information Officer, CareGroup Healthcare System and Harvard Medical School; Attending Physician, Division of Emergency Medicine, Beth Israel Deaconess Medical Center
John D Halamka, MD, MS is a member of the following medical societies: American College of Emergency Physicians, American Medical Informatics Association, Phi Beta Kappa, and Society for Academic Emergency Medicine
Disclosure: Nothing to disclose.

Chief Editor

Pamela L Dyne, MD, Professor of Clinical Medicine/Emergency Medicine, David Geffen School of Medicine at UCLA; Attending Physician, Department of Emergency Medicine, Olive View-UCLA Medical Center
Pamela L Dyne, MD is a member of the following medical societies: American Academy of Emergency Medicine, American College of Emergency Physicians, and Society for Academic Emergency Medicine
Disclosure: Nothing to disclose.

Further Reading