Септичний аборт

Symptoms and signs of septic abortion typically appear within 24 to 48 hours after abortion and are similar to those of pelvic inflammatory disease (eg, chills, fever, vaginal discharge, often peritonitis) and often those of threatened or incomplete abortion (eg, vaginal bleeding, cervical dilation, passage of products of conception). Perforation of the uterus during the abortion typically causes severe pelvic or abdominal pain.

Septic shock may result, causing hypothermia, hypotension, oliguria, and respiratory distress. Sepsis due to C. perfringens may result in thrombocytopenia, ecchymoses, and findings of intravascular hemolysis (eg, anuria, anemia, jaundice, hemoglobinuria, hemosiderinuria).

• Vital signs and pelvic and abdominal examination

• Blood cultures to guide antibiotic therapy

• Complete blood count and other tests to evaluate patient status

• Ultrasonography

Septic abortion is usually obvious clinically, typically based on finding symptoms and signs of severe infection in women who are or recently were pregnant. Ultrasonography should be done to check for retained products of conception as a possible cause. Uterine perforation should be suspected when women have unexplained severe abdominal pain and peritonitis. Ultrasonography is insensitive for detecting perforation.

When septic abortion is suspected, aerobic and anaerobic cultures of blood are done to help direct antibiotic therapy. Laboratory tests should include complete blood count (CBC) with differential, liver function tests, electrolyte levels, glucose, blood urea nitrogen (BUN), and creatinine. Prothrombin time (PT) and partial thromboplastin time (PTT) are done if liver test results are abnormal or if women have excessive bleeding. Products of conception should be sent to microbiology if possible. In patients with septicemia, evaluate for group A Streptococcus and Clostridia.

• Intravenous empiric broad-spectrum antibiotic therapy (eg, clindamycin plus gentamicin with or without ampicillin)

• Uterine evacuation

• Sometimes pelvic or abdominal imaging

Treatment of septic abortion includes intravenous broad-spectrum antibiotic therapy, which should be initiated immediately. Choice of antibiotics should take into consideration that infections are polymicrobial, and treatment should cover gram-positive, gram-negative, and anaerobic bacteria. A typical empiric antibiotic regimen includes clindamycin 900 mg IV every 8 hours plus gentamicin 5 mg/kg IV once a day, with or without ampicillin 2 g IV every 4 hours. Alternatively, a combination of ampicillin, gentamicin, and metronidazole 500 mg IV every 8 hours can be used. Antibiotic regimen may be modified based on culture results.

In addition, uterine evacuation should be performed once the patient is stable. Patients with bleeding or suspected uterine perforation or organ damage may need further imaging (eg, MRI).

• Septic abortions usually result from use of nonsterile techniques for uterine evacuation after induced or spontaneous abortion; they are much more common after induced abortion procedures done by untrained clinicians using nonsterile techniques.

• Septic abortion could also arise from an incomplete abortion that was secondarily infected due to an open cervical os.

• Symptoms and signs (eg, chills, fever, vaginal discharge, peritonitis, vaginal bleeding) typically appear within 24 to 48 hours after an abortion. Patients could also present with severe unexplained pelvic or abdominal pain.

• If septic abortion is suspected, immediately begin treatment with broad-spectrum antibiotics followed by prompt uterine evacuation; obtain blood cultures to guide antibiotic therapy.