eMedicine Specialties > Emergency Medicine > Obstetrics & Gynecology
Abortion, Septic: Treatment & Medication
Updated: Dec 17, 2008
- Overview
- Differential Diagnoses & Workup
- Treatment & Medication
- Follow-up
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.
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
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
Documented hypersensitivity; severe hepatic dysfunction
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.
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
Probenecid may increase effects of cefoxitin; coadministration with aminoglycosides or furosemide may increase nephrotoxicity (closely monitor renal function)
Documented hypersensitivity
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.
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
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)
Documented hypersensitivity; non–dialysis-dependent renal insufficiency
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.
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
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
Documented hypersensitivity; severe pneumonia, bacteremia, pericarditis, emphysema, meningitis, and purulent or septic arthritis should not be treated with PO penicillin during acute stage
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.
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
Coadministration with cyclosporine may increase CNS adverse effects of both agents; coadministration with ganciclovir may result in generalized seizures
Documented hypersensitivity
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.
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
Probenecid and disulfiram elevate ampicillin levels; allopurinol decreases ampicillin effects and has additive effects on ampicillin rash; may decrease effects of PO contraceptives
Documented hypersensitivity
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.
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
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
Documented hypersensitivity
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
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.
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
Increases duration of neuromuscular blockade induced by tubocurarine and pancuronium; erythromycin may antagonize effects of clindamycin; antidiarrheals may delay absorption of clindamycin
Documented hypersensitivity; regional enteritis; ulcerative colitis; hepatic impairment; antibiotic-associated colitis
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.
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
Probenecid may increase cefotaxime levels; coadministration with furosemide and aminoglycosides may increase nephrotoxicity
Documented hypersensitivity
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.
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
Probenecid may increase ceftriaxone levels; coadministration with ethacrynic acid, furosemide, and aminoglycosides may increase nephrotoxicity
Documented hypersensitivity
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.
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
Pressor effect of sympathomimetics may increase when used concomitantly with oxytocic drugs, causing postpartum hypertension
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)
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
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References
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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].
Further Reading
Keywords
septic abortion, miscarriage, spontaneous abortion, therapeutic abortion, artificial abortion, pelvic infection, pelvic inflammatory disease, PID
