Septic abortion

Septic abortion

Definition:

Any abortion associated with clinical evidence of infection of the uterus and its contents, is called septic abortion. Although criteriavary, abortion is usually considered septic when there are: (1) rise of temperature of at least 100.4°F (38˚C) for 24 hours or more; (2) offensive or purulent vaginal discharge and (3) other evidences of pelvic infection such as lower abdominal pain and tenderness.

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

Incidence:

      About 10% of the abortion requiring admission to hospital are septic. The majority of septic abortions are associated with incomplete abortion. While in the majority of the cases the infection occur following illegal induced abortion but infection can occur even after spontaneous abortion.

Mode of infection:

      The micro-organisms involved in the sepsis are usually those normally present in the vagina (endogenous). Thus there growth in the culture media as to be interpreted in relation to clinical manifestation.

       The micro-organisms are: (a) anaerobic-bacteroides group (fragilis) anaerobic streptococci, cl. Welchii, and tetanus bacillus. (b) aerobic-Escherichia coli (E, coli). Klebsiella, staphylococcus, pseudomonas and haemolytic streptococcus (usually exogenous). Mixed infection is more common. When the general condition of the patient becomes low due to blood loss or the local tissue resistance becomes impaired due to trauma or the presence of the nidus (retained products) for the bacteria to grow-the organisms become pathogenic. The increased association of sepsis in illegal induced abortion is due to the fact that: (1) proper antiseptic and asepsis are not taken; (2) incomplete evacuation and (3) inadvertent injury to ht genital organs and adjacent structures, particularly the gut.  

Pathology

In the majority (80%), the organisms are of endogenous origin and the infection is localized to the conceptus without any myometrial involvement. In about 15%, the infection either produces localized endomyometritis surrounded by a protective leucocytic carrier, or spreads to the parametrium, tubes, ovaries or pelvic peritoneum. In about 5%, there is generalized peritonitis and/or endotoxic shock.

Clinical features:

pyrexia: associated with the chills and rigors suggest blood stream spread of infection. However, if subnormal temperature is present, it is an ominous feature of endotoxic shock.

pain abdomen

a rising pulse rate of 100-120/minute or more is a significant finding than even pyrexia.it indicates spread of infection beyond the uterus.

variable systemic and abdominal findings depending up on the spread of infection.

internal examination reveals offensive purulent vaginal discharge or a tender uterus usually with patulous os or a boggy feel of the uterus associated with variable pelvic findings depending up on the spread of infection.

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.

Clinical grading:

Grade – I: the infection is localized in the uterus.

Grade – II: The infection spreads beyond the uterus to the parametrium, tubes and ovaries or pelvic peritoneum.

Grade – III: Generalised peritonitis and/or endotoxic shock or jaundice or acute renal failure.

Grade – I: is the commonest and usually associated with spontaneous abortion. Grade-III is almost

associated with illegal induced abortion.

Investigations:

Routine investigation include: (1) cervical or high vaginal swab is taken prior to internal examination for – (a) culture in aerobic and anaerobic media to find out the dominant micro-organisms, (b) sensitivity of the micro-organisms to antibiotics and (c) smear for gram stain. Gram negative organisms are: E. coli, pseudomonas, bacteroides etc. gram positive organisms are: staphylococci, anaerobic streptococci, cl. tetani etc.  (2) blood for haemogobin estimation, total and differential count of white cells, ABO and Rh grouping. (3) urine analysis including culture.

Special investigations:(1) ultrasonography pelvis and abdomen to detect intrauterine retained products of conception, foreign body. (2) X-ray abdomen and pelvis- not commonly done these days. (3) Blood- ( a) culture- if associated with spell of chills and rigors, (b) serum electrolytes- as an adjunct to the management protocol of endotoxic shock. (c) Coagulation profile.

Complications:

Immediate:

  • Haemorrhage related due to abortion process and also due to injury inflicted during the interference.
  • Injury may occur to the uterus and also to the adjacent structures particularly gut.
  • Spread of infection leads to: (a) generalised peritonitis – the infection reaches through: (i) uterine tubes, (ii) perforation of the uterus, (iii) bursting of the microabscess in the uterine wall and (iv) injury to the gut. (b) Endotoxic shock- mostly due to E. coli or cl. Welchii infection. (c) Acute renal failure – motile factors are involved in producing patchy cortical necrosis or acute tubular necrosis. It is common in infection with cl. Welchii. (d) Thrombophlebitis.

 Remote: (a) Chronic debility (b) chronic pelvic pain and backache (c) dyspareunia (d) ectopic pregnancy (e) secondary infertility due to tubal blockage and  (f) emotional depression.

Management

General management:

  • Hospitalisation even with a case of mild infection is preferable. The patient should be kept in isolation, if possible.
  • To take high vaginal swab for culture, drug sensitivity test and gram stain.
  • Vaginal examination is then made to note the state of the abortion process and extension of the infection. If the products are found loosely lying in the cervix, they should be removed by sponge holding forceps.
  • Overall assessment of the case is to be done and the patient is put in accordance with the clinical grading.
  • Investigation protocols as outlined before are done as required and where available.
  • To formulate the line of treatment which aims at – (a) to control sepsis. (b) To remove the source of infection. (c) To give supportive therapy to bring back the normal statistic and cellular metabolism. (d) To remain vigilant in order to assess the response of the treatment.

Grade – I:

Drugs:

(1) antibiotics

(2) Prophylactic ant gas-gangrene serum of 8000 units of antitetanus serum intramuscularly is given if there is a history of interference.

(3) Analgesics and sedatives, as required are to be prescribed.

Blood transfusion: early and adequate blood transfusion is not only helpful to improve the body resistance and anaemia but is also affective to prevent or minimize shock and oliguria.

Evacuation of the uterus: As abortion is often incomplete, evacuation should be performed at a convenient time within 24 hours following antibiotic therapy. Excessive bleeding is, of course, an urgent indication for evacuation. Early emptying not only minimizes the risk of  haemorrhage but also removes the nidus of infection. Gentleness and avoidance of vigorous curettage are to be followed to minimize the risk of injury to the soft uterus and spread of infection into the deeper tissues.

GRADE – II :

Drugs: Antibiotics – Mixed infections including gram positive, gram negative and anaerobic organisms are common. Ideal antibiotic regimens should cover all of them.

  1. For gram positive aerobes: (a) Aqueous penicillin G 5 million units I.V. every 6 hours, or (b) Ampicillin 0.5 – 1 Gm I.V. every 6 hours. B. Gram negative aerobes: (a) Gentamicin 1.5 mg/kg I.V. every 8 hours  (Serum level to be monitored in a case with renal failure and dose to be adjusted accordingly) or (b) Cefuroxime 1.5G, I.V. every 8 hours. C. For anaerobes: Metronidazole 500 mg I.V.  Every 8 hours, or Clindamycin 600 mg I.V. evry 6 hours.

Antibiotic regimens have to be modified according to the culture and sensitivity report as obtained later.

Clinical monitoring: To note pulse, respiration, temperature, urinary output and progress of the pain, tenderness and mass in lower abdomen.

Surgery:

 (1) Evacuation of the uterus – Evacuation should be withheld for at least 48 hous after the infection is controlled and becomes localized, the only exception being excessive bleeding.

(2) Posterior colpotomy – When the infection is localized in the pouch of Douglas, pelvic abscess is formed. It is evidenced by spiky rise of temperature, rectal tenesmus (frequent loose stool mixed with mucus) and boggy mass felt through the posterior fornix. Posterior colpotomy and drainage of the pus relieve the symptoms and improve the general outlook of the patient.

GRADE – III:

Antibiotics are discussed above. Clinical monitoring is to be conducted as outlined in grade-II. Supportive therapy is directed to treat generalized peritonitis by gastric suction and intravenous saline infusion. Management of endotoxic shock.

Active surgery:

            Along with the antibiotic therapy and the resuscitation of the paient with the fluid and electrolyte, the patient should be assessed as to whether active surgery is needed. The indications of active surgery are: (1) Injury to the uterus (2) Suspected injury to the gut (3) Presence of foreign body in the abdomen as evidenced by the sonography or X-ray or felt through the formix on bimanual examination (4) Unresponsive peritonitis suggestive of collection of pus (5) Septic shock or oliguria not responding to the conservative treatment (6) Uterus too big to be safely evacuated per vaginam.

            The laparotomy should be done by experienced surgeon with a skilled anaesthetist. Removal of the uterus should be done by its own merit irrespective of parity. Adnexa is to be removed or reserved according to the pathology found. Thorough inspection of the gut and omentum for evidence of any injury is mandatory. Even when nothing is found on laparotomy, simple drainage of the pus is effective.