Frances Casey and Katie P. Friday
History of present illness
A 36-year-old gravida 1, para 0 woman at 14 weeks’gestation by in-vitro fertilization presented complaining of 1 day of fever, abdominal pain, and vaginal bleeding. She described having an intermittent watery vaginal discharge for the past two weeks, which she thought was normal. Several hours prior to presen- tation, the patient experienced bright red vaginal spotting with passage of small clots. She also had nausea with several episodes of vomiting. She described her pain as cramping across her lower abdomen, rated at a level of 9 on a scale of 0–10.
Gynecologic history was significant for infertility and endometriosis. She has no other significant medical or surgical history. She takes no medications other than a prenatal vitamin.
Physical examination
General appearance:Woman who is tearful and in moderate discomfort
Vital signs:
Temperature: 38.9°C Pulse: 110 beats/min
Blood pressure: 95/65 mmHg Respiratory rate: 20 breaths/min Oxygen saturation: 98% on room air HEENT: Unremarkable
Cardiovascular: Tachycardic, regular rhythm without murmurs, rubs, or gallops
Lungs: Clear to auscultation bilaterally
Abdomen:Soft, nondistended, diffusely tender to palpation with significant fundal tenderness, fundus consistent with 14 weeks’gestation
Pelvic: Blood-tinged, foul-smellingfluid pooling in vagina on speculum exam, active bleeding visualized at external os.
Internal os 1 cm dilated. Cervical motion tenderness present.
Fourteen-week-sized diffusely tender uterus. Adnexa not palpable
Laboratory studies:
CBC: Leukocytosis of 13 100/àL (normal 3500–12 500/àL) with 89% neutrophils (normal 50–70%)
Hb: 9.7 g/dL (normal second-trimester pregnancy 9.7–14.8 g/dL)
Ht: 29.2% (normal second-trimester pregnancy 30–39%) Platelets: 139 ì 103/àL (normal second-trimester
pregnancy 155–409 ì 103/àL)
Urinalysis: Clear color, negative for nitrites, glucose, protein, and small leukocytes
Serum electrolytes, renal, and liver functions: Normal Blood cultures: Sent
Imaging:Transabdominal sonogram (Fig. 50.1) showed a singleton gestation with anhydramnios, located in the lower uterine segment, crown–rump length measuring 8.01 cm consistent with 14 weeks, fetal heart rate 193 beats/min, placenta posterior
How would you manage this patient?
This patient has a septic abortion. The two-week history of clear fluid leaking combined with absence of fluid on sonogram indicates ruptured membranes. This patient is clearly infected as evidenced by tachycardia, temperature to 38.9°C, and a white blood cell count of 13 100/μL. Intrauterine infection is clear from the diffusely tender uterus and foul-smellingfluid leaking from the cervix. Pyelonephritis, another common source of fever in pregnancy, is ruled out with a normal urinalysis.
Blood and urine cultures were obtained, as were cervical nucleic acid amplification tests (NAATs) for gonorrhea and chlamydia. An IV was started and she was rehydrated. She received doses of ampicillin, gentamicin, and clindamycin.
She underwent an immediate uncomplicated dilation and evacuation under intravenous sedation in the operating room.
She was hospitalized postoperatively and broad-spectrum antibiotics were continued until all signs of infection had
Fig. 50.1 Singleton intrauterine pregnancy 14 weeks with oligohydramnios.
Acute Care and Emergency Gynecology, ed. David Chelmow, Christine R. Isaacs and Ashley Carroll. Published by Cambridge University Press.
© Cambridge University Press 2015.
resolved for 48 hours. Blood cultures were positive for Escherichia coli.
Septic abortion
A septic abortion is a spontaneous or induced abortion com- plicated by infection of the products of conception. Septic abortion has most commonly been described in cases of illegal or incomplete induced abortions. In the United States, cases of septic abortion and other abortion-related morbidity and mor- tality decreased dramatically following legalization of abortion services [1]. Nevertheless, as recently as 2009, a case report described a self-attempted abortion with a coat hanger resulting in sepsis, acute respiratory distress syndrome, and a total abdominal hysterectomy with bilateral salpingo- oophorectomy [2]. Septic abortion is less common during a spontaneous abortion but can occur with retained products or in the setting of prolonged rupture of membranes, as in this case. Other risk factors for septic abortion include concomi- tant infection with Chlamydia trachomatis, immune com- promise, and an intrauterine device left in-situ during a pregnancy.
Septic abortions remain one of the leading causes of mater- nal mortality worldwide. Countries with safe, legal access to abortion services have mortality rates of 1/100 000 as com- pared to mortality rates as high as 460/100 000 in regions with poor access [3]. Disparities between countries in abortion- related mortality can be attributed to a number of factors including: abortion legislation, stigma, socioeconomic status [4], contraceptive coverage, and the availability of safe, access- ible, comprehensive abortion services [5,6].
A septic abortion may present with fever, tachycardia, uterine tenderness, foul-smelling discharge or vaginal bleed- ing, and lower abdominal pain. Other signs and symptoms may include chills, oliguria, jaundice, and malaise. Presenta- tions may range from mild illness characterized by low-grade fever, mild abdominal pain, and vaginal bleeding to multi- organ failure characterized by tachycardia, tachypnea, hypo- tension, and an inability to regulate body temperature.
A strong suspicion and early recognition of sepsis is important to decrease morbidity and mortality. This patient presented with mild symptoms, but with blood cultures positive for Escherichia coli, a delay in diagnosis and treatment could have resulted in multiorgan failure within hours.
Immediate treatment includes aggressive hydration, broad- spectrum antibiotics, and evacuation of uterine contents.
A delay in treatment can result in bacteremia, pelvic abscess, septic pelvic thrombophlebitis, disseminated intravascular coa- gulopathy, septic shock, organ failure, and death [7].
Infections may be polymicrobial and involve gram- negative or gram-positive aerobes, facultative or obligate anaerobes, and sexually transmitted pathogens [7]. The most common organisms includeEscherichia coli, enterococci, and beta-hemolytic streptococci. Because of the variety of possible agents, no single antibiotic is ideal [8]. Broad-spectrum antibi- otics must be started as soon as the diagnosis is suspected after
obtaining blood and urine cultures and cervical NAATs. Anti- biotic regimens typically include ampicillin (2–3 g IV every 6 h), clindamycin (900 mg IV every 8 h), and gentamicin (loading dose of 2 mg/kg body weight given IV followed by 1.5 mg/kg every 8 h, depending on renal status). Alternative antibiotics with broad-spectrum coverage may also be appro- priate. Antibiotics may be tailored once cultures and sensitiv- ities have been reported. For milder infections, single agents may be appropriate. Following 48 hours of clinical improve- ment, antibiotics may be discontinued.
Evacuation can be performed efficiently in thefirst trimes- ter with electric or manual vacuum aspiration under local anesthesia or with minimal intravenous sedation. This can be performed at the bedside if a patient is too ill for movement to the operating room. In the case illustrated, the patient had early sepsis, was stable for transfer to the operating room, and dilation and evacuation was accomplished using deep sedation.
In the second trimester, a trained provider can perform evacu- ation of fetal tissue or retained products using forceps under ultrasound guidance. Rapid surgical evacuation is mandatory to achieve clinical improvement and every attempt should be made to facilitate surgical evacuation. Clearly, dilation and time required for uterine evacuation will increase with gesta- tional age. The operating room team must be prepared to manage disseminated intravascular coagulation and hemor- rhage, with conversion to hysterectomy if necessary, as these risks are increased in cases of sepsis.
Medication abortion prolongs induction-to-delivery interval and still may require surgical evacuation for retained products of conception. However, if a trained provider is not available, alternative methods of uterine evacuation must be employed according to availability. First- and second-trimester cases could be managed using Hemabate® (carboprost trometha- mine), Cytotec® (misoprostol), or Cervidil® (dinoprostone).
No studies of misoprostol in the setting of septic abortion have been published, but given its widespread availability, efficacy, and few adverse side effects outside of temperature increase, nausea, and vomiting, misoprostol could facilitate uterine evacuation if surgical methods are not available.
While oxytocin has been employed for early induction, it has prolonged induction-to-delivery interval and concern for water intoxication compared to misoprostol. In the second-trimester mechanical dilation can be achieved with a 30 mL Foley catheter balloon placed in the lower uterus and taped to maternal leg for traction [7,9].
Key teaching points
Immediate treatment includes aggressive hydration, broad- spectrum antibiotics, and evacuation of uterine contents.
Rapid surgical evacuation is mandatory to achieve clinical improvement. If surgery is not available, alternative means of uterine evacuation must be employed, although surgery is preferred.
The availability of safe, legal abortion services decreases maternal mortality and morbidity due to septic abortion.
Case 50: A 36-year-old woman with fever and pelvic pain at 14 weeks’gestation
References
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The back alley revisited: Sepsis after attempted self-induced abortion.
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