Septic Abortion

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Introduction

Septic abortion is a life threatening complication of abortion. Most often there is a history of criminal interference with the pregnancy.

It may lead to complications such as septic shock, uterine damage, peritonitis, haemorrhage, disseminated intravascular coagulation (DIC), acute renal failure, adult respiratory distress syndrome, tetanus or gas gangrene.

We have different types of abortion which include complete abortion, septic abortion, safe abortion, missed abortion, inevitable abortion, incomplete abortion, threatened abortion etc.

Causes of Septic abortion

Septic abortion is caused by:

  • Infected retained products of conception

Symptoms of septic abortion

The symptoms of Septic abortion include the following:

  1. Severe lower abdominal pain
  2. Fever
  3. Vomiting
  4. Headache
  5. Offensive, bloody vaginal discharge

Signs of septic abortion

The following are the signs of septic abortion:

  1. Fever (but temperature may be normal)
  2. Tachycardia
  3. If in septic shock: low blood pressure
  4. Peritonism
  5. Bulky tender uterus
  6. Cervix may be opened or closed
  7. Retained offensive products of conception

Investigations

  • FBC and sickling test
  • Clotting screen
  • Blood grouping and cross matching
  • Blood culture and sensitivity
  • Urine culture and sensitivity
  • Endo-cervical swab for culture and sensitivity
  • Blood urea and electrolytes
  • Chest and abdominal X-ray (to exclude foreign body, gas under the diaphragm suggesting uterine perforation)
  • Abdomino-pelvic ultrasonography (for intra-abdominal and pelvic abscesses, presence of products in uterus, fluids and gas in the pelvis)

Treatment

Treatment objectives

The treatment objectives of septic abortion include the following:

  1. To resuscitate patient
  2. To treat infection
  3. To evacuate uterus
  4. To provide post-abortion counselling

Non-pharmacological treatment

  1. Evacuate the retained products of conception (careful evacuation of the uterus must be done as risk of uterine perforation is high)
  2. Gentle digital curettage followed by the instrumental curettage under general anaesthesia within 6 hours of initiation of antibiotic therapy
  3. Examine to confirm if uterus is perforated and determine if surgery is required
  4. Psychological support and family planning counselling

Pharmacological treatment

A. Resuscitation for shock

Evidence Rating: [A]

  • IV fluids and blood transfusion as necessary

B. Treatment of Sepsis

Amoxicillin + Clavulanic Acid, IV,

  • 1.2 g 8 hourly for 24-72 hours

And

Gentamicin, IV,

  • 80 mg 8 hourly for 5 days

And

Metronidazole, IV,

  • 500 mg 8 hourly for 24-72 hours

Note

Culture and sensitivity test results will direct further antibiotic therapy.
IV antibiotic therapy should be continued until the patient is afebrile for at least 24 hours.
Oral therapy should be continued for at least seven days.
If Gentamicin is to be continued, give 80 mg IM or IV 8 hourly for at least 5 days.

C. Evacuate uterus

Note

To abort foetus if still in utero and/or if surgical evacuation of products is not immediately possible.

Oxytocin, IV infusion
(See ‘Inevitable Abortion‘ for details)

Or

Misoprostol, sublingual oral or vaginal,

  • 600 microgram stat.

(See ‘Incomplete Abortion‘ for details)

D. Severe Pain management

Evidence Rating: [C]

Morphine, IV,

  • 2.5-5 mg 4 hourly as required

And

Metoclopramide, IV,

  • 5-10 mg 8 hourly as required for vomiting

Or

Pethidine, IM,

  • 50-100 mg 4-6 hourly (Maximum 400 mg in 24 hours)

And

Promethazine, IV/IM,

  • 25 mg 8-12 hourly as required (max. 25 mg 6 hourly) to reduce the chances of vomiting and to potentiate the analgesic effect of Pethidine

E. Tetanus Prophylaxis

Tetanol, IM, 0.5 ml stat.

And

Human Immune Tetanus Globulin, IM,

  • 250-500 units stat.

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