Erin L. Murata and Tony Ogburn
History of present illness
A 22-year-old gravida 1, para 0 woman presents to the emergency department with complaints of severe pelvic pain and fever to 38.3°C. She reports she underwent a surgical abortion at nine weeks’ gestation at an outpatient clinic four days ago. She reports the procedure was uncomplicated and she recalls being given oral antibiotics prior to the procedure.
She was well until she noted pelvic discomfort and a foul- smelling discharge two days ago. She has continued to have menstrual-like bleeding since the procedure. Her past medical history is unremarkable. She complains of nausea but no emesis. She has a prescription for birth control pills that she plans to start within the next week.
Physical examination
General appearance:Young woman in no acute distress Vital signs:
Temperature: 38.5°C Pulse: 102 beats/min
Respiratory rate: 18 breaths/min Blood pressure: 100/55 mmHg Oxygen saturation: 98% on room air
Abdomen:Soft, nondistended, tender to palpation in the suprapubic region, no peritoneal signs
Pelvic:External genitalia: normal
Vagina:Small amount of malodorous dark blood noted in vaginal vault
Cervix:Nulliparous appearing, small amount of blood in os
Uterus:Slightly enlarged, anteverted with moderate cervical motion and fundal tenderness
Adnexa:Moderate tenderness, no masses palpable Laboratory studies:
WBCs: 14 200/μL Ht: 36.0%
Imaging:Pelvic ultrasound showed an endometrial thickness of 2.7 cm consistent with retained tissue (Fig. 5.1a,b)
How would you manage this patient?
The patient has post-abortal endometritis with retained products of conception (POC). Patients with post-abortal endometritis should be treated with broad spectrum
antibiotics. Treatment can be oral or intravenous depending on the severity of the infection and the patient’s ability to tolerate oral medications. If retained POC are suspected on ultrasound, re-aspiration should be performed. This patient’s ultrasound demonstrates a heterogeneous and thickened endo- metrium with normal appearing adnexa (not seen inFig. 5.1a, b), raising concern for retained POC. There was no evidence of an abscess on her ultrasound.
This patient’s symptoms and findings were consistent with endometritis with retained products. She did not appear severely ill but was complaining of nausea, so parenteral antibiotics were administered. The patient underwent an initial loading dose of intravenous antibiotics followed by uterine re-aspiration. The procedure can be performed in the outpa- tient or inpatient setting with electronic suction or a manual vacuum aspirator. Because of her nausea she was admitted overnight for hydration and continued observation. She did well overnight and was discharged home the next day to continue oral antibiotics (doxycycline 100 mg PO BID) for 14 days.
Post-abortal endometritis
Infection after first-trimester-induced abortion occurs with a reported frequency of 0.1–5.0% for first-trimester surgical termination, with most studies in the United States in the 0.1–2.0% range. The variation in reported frequency stems from differences in ascertainment of cases and definitions of infection among studies [1]. The incidence of retained POC followingfirst-trimester abortion ranges from 0.29 to 1.96%.
Infection may manifest with pyrexia, pelvic pain or discomfort, persistent vaginal bleeding, and malodorous or purulent vaginal discharge. Findings on examination may include abnormal vital signs, including fever, tachycardia, and hypotension, as well as abdominal and pelvic tenderness, malodorous vaginal discharge, vaginal bleeding, cervical motion tenderness, and palpable tubo-ovarian abscess.
Laboratory evaluation is typically limited to a complete blood count (CBC) and nucleic acid amplification tests (NAATs) for gonorrhea and chlamydia if the patient did not have them prior to the procedure. Vaginal, uterine, and blood cultures are not typically helpful and should not be obtained routinely.
Imaging should include pelvic ultrasound as retained POC is a finding often associated with post-abortal infection.
A thickened and heterogeneous endometrial stripe on ultra- sound should raise suspicion for retained products. There are
Acute Care and Emergency Gynecology, ed. David Chelmow, Christine R. Isaacs and Ashley Carroll. Published by Cambridge University Press.
© Cambridge University Press 2015.
no definitive criteria for diagnosis of retained products on ultrasound. Hematometra or decidual tissue can have a similar appearance [2]. Additional imaging studies such as CT or MRI are not indicated unless pelvic abscess or other etiology, such as appendicitis or bowel injury with perforation, is suspected.
In this case, the patient’s examination is not consistent with a bowel injury as she had no peritoneal signs.
Genital tract infection following termination is usually polymicrobial with bacteria originating from the genital tract.
Upper genital tract involvement is caused by ascending infec- tion and can result in endometritis or pelvic inflammatory disease, while lower genital tract infection may manifest as vaginitis. Severe infection is rare afterfirst-trimester abortion but can occur with the development of pelvic abscess, sepsis, or toxic shock syndrome. While endometritis typically presents with fever, pain, and bleeding, severe infection may present with bacteremia and hypotension with sepsis, or acute-onset cardiovascular collapse as in the case of toxic shock syndrome [3]. The patient with a pelvic abscess usually appears ill and will typically havefindings on imaging.
Treatment of acute infection
Post-abortal infection should be treated promptly as it can progress to severe infection with the development of pelvic abscess or sepsis. In addition, there are associated long-term sequelae including increased risk of ectopic pregnancy, infertil- ity, and chronic pelvic pain that may be diminished by timely treatment. In one large randomized trial, outpatient treatment appears to be as effective as inpatient treatment in resolution of disease as well as prevention of long-term sequelae [4]. This study excluded pregnant and post-abortal patients, but in the absence of data specific to such patients, a similar treatment approach may be utilized.
Treatment of the acute post-abortal infection should be guided by the patient’s presentation and severity of infection.
Uncomplicated infection may be treated with oral antibiotics if the patient is able to tolerate and comply with the regimen.
Severe infection or patient inability to tolerate oral medication should prompt hospital admission and treatment with intra- venous broad spectrum antibiotics.
(b)
(a) Fig. 5.1 (a,b) Retained products of conception.
Patients with signs of sepsis require aggressive treatment with antibiotics and re-aspiration and may requirefluid resusci- tation and possibly pressors if hypotension develops. In the rare case of patients with toxic shock syndrome, treatment should be expeditious and aggressive with prompt fluid resuscitation, administration of pressors and broad spectrum antibiotics, and consideration of surgical intervention (e.g. hysterectomy).
Patients with pelvic abscess may require percutaneous drainage or surgical intervention in addition to intravenous antibiotics.
Current antibiotic regimens for the treatment of post- abortal infection vary, but due to the polymicrobial nature of these infections, initial therapy should be broad spectrum. The regimens recommended by the Centers for Disease Control and Prevention (CDC) [5] for treatment of pelvic inflamma- tory disease are appropriate for post-abortal infections. Rec- ommended regimens are summarized in Table 5.1. Initial therapy for the uncomplicated patient should include parenteral cefoxitin (2 g + 1 g of probenicid) or ceftriaxone (250 mg) plus doxycycline 100 mg PO BID for a total of 14 days. Alternate oral regimens including the use of quinolones may not be as effective due to increased resistance. Patients who have worsening or persistent infection despite outpatient treatment, or who are unable to tolerate oral antibiotics, should be admitted for intravenous antibiotic therapy.
Parenteral treatment for severe infection or failed outpa- tient treatment includes doxycycline 100 mg IV BID with
cefoxitin 2 g IV daily, or clindamycin 900 mg every 8 hours plus an aminoglycoside such as gentamicin at a dose of 1.5 mg/kg IV every 8 hours. Once the patient has stabilized and is improving, parenteral antibiotics may be discontinued and followed by a 14-day course of an acceptable oral antibi- otic regimen such as doxycycline.
Retained products
In the patient with endometritis, if ultrasound suggests retained POC, uterine evacuation should occur promptly in conjunction with antibiotic administration. Thorough imaging, including Doppler assessment, is useful in the detection of retained prod- ucts, but some cases may be missed. Consideration should be given to curettage in patients that fail antibiotic therapy, even if there is no evidence of retained products on ultrasound. If tissue is present in the cervical os, it should be removed.
Patients with retained POC without symptoms of infection may be managed expectantly, medically with an uterotonic agent, such as misoprostol, or surgically.
Prevention of post-abortal infection
Appropriate equipment and technique will prevent most infectious morbidity [6]. Prophylactic antibiotics decrease the incidence of post-abortal infection and universal adminis- tration is more effective than risk-based or screen-and-treat approaches.
A meta-analysis published in the mid-1990s concluded that prophylaxis in all patients prior to induced abortion decreases the rate of infection by over 40%, is cost-effective, and should be universally employed [7]. As such, all patients undergoing surgical termination should receive prophylactic antibiotics prior to the procedure regardless of their risk factors. Though the optimal antibiotic and regimen has not been determined, tetracyclines and nitroimidazoles are effective. Doxycycline is the most common antibiotic utilized in the United States.
The American College of Obstetricians and Gynecologists (ACOG) recommends doxycycline 100 mg PO 1 hour before the procedure and 200 mg PO after the procedure, or metronidazole 500 mg PO BID for 5 days after the procedure [8]. The Society of Family Planning (SFP) recommends administering doxycycline within 12 hours of a surgical ter- mination [9]. Taking the medication the night before the procedure is effective and may decrease the incidence of peri- operative nausea and vomiting.
Contraception after abortion
Patients undergoing termination of pregnancy typically need effective contraception. It is acceptable, and it may be preferable, to place an intrauterine device (IUD) immediately after a surgical abortion [10]. There is no increase of expulsion or infectious complications and repeat unintended pregnancy may be decreased. If a patient with an IUD placed immediately after an abortion subsequently presents with
Table 5.1 Recommended antibiotic regimens for treatment of post-abortal endometritis*
Parenteral regimens
A. Cefotetan 2 g IV every 12 hours ORCefoxitin 2 g IV every 6 hours
PLUSDoxycycline 100 mg PO or IV every 12 hours
B. Clindamycin 900 mg IV every 8 hours PLUS
Gentamicin loading dose IV or IM (2 mg/kg of body weight), followed by a maintenance dose (1.5 mg/kg) every 8 hours. Single daily dosing (3–5 mg/kg) can be substituted
Oral regimens
A. Ceftriaxone 250 mg IM in a single dose PLUSDoxycycline 100 mg PO BID for 14 days WITH or WITHOUT
Metronidazole 500 mg PO BID for 14 days
B. Cefoxitin 2 g IM in a single dose and probenecid, 1 g PO administered concurrently in a single dose
PLUS
Doxycycline 100 mg PO BID for 14 days WITH or WITHOUT
Metronidazole 500 mg PO BID for 14 days
* Adapted from Centers for Disease Control and Prevention [5].
BID, twice a day; IM, intramuscularly; IV, intravenously; PO,per os(orally).
Case 5: Bleeding, pain, and fever four days afterfirst-trimester termination
an infection, the IUD may be left in place while antibiotic treatment is initiated. If the patient does not improve as expected, consideration should be given to removal of the IUD. In the patient with infection and retained products that requires re-aspiration, the IUD should be removed. In patients with retained tissue on imaging, but no evidence of infection, the IUD may be left in place and the patient treated expectantly or with medication.
Patients with post-abortal infection who are not using an effective contraceptive method should be counseled about their options. Except for the IUD, where insertion is contraindicated in the setting of acute infection, all methods can be initiated at this time including the implant, depot medroxyprogesterone acetate injection (Depo-Provera®CI), or combination hormo- nal methods.
Key teaching points
Infection and retained tissue followingfirst-trimester abortion is rare.
Post-abortal infection should be treated promptly and with broad spectrum antibiotics.
If retained tissue is present in the infected patient, re-aspiration should be performed. Re-aspiration is not necessary in the uninfected patient with retained tissue.
In the uncomplicated patient, therapy may be performed as an outpatient.
Effective contraception, including long-acting reversible contraception, should be offered to post- abortion patients.
References
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