Septic abortion describes any type of abortion (intentional termination or miscarriage), due to an upper genital tract bacterial infection including the inflammation of the
endometrium
The endometrium is the inner epithelial layer, along with its mucous membrane, of the mammalian uterus. It has a basal layer and a functional layer: the basal layer contains stem cells which regenerate the functional layer. The functional laye ...
during or after 20 weeks of
gestation
Gestation is the period of development during the carrying of an embryo, and later fetus, inside viviparous animals (the embryo develops within the parent). It is typical for mammals, but also occurs for some non-mammals. Mammals during pregna ...
.
The genital tract during this period is particularly vulnerable to infection, and
sepsis
Sepsis, formerly known as septicemia (septicaemia in British English) or blood poisoning, is a life-threatening condition that arises when the body's response to infection causes injury to its own tissues and organs. This initial stage is follo ...
in most cases is caused by a combination of factors both due to facility conditions and/or individual predispositions. The infection often starts in the placenta and fetus, with a potential complication of also affecting the uterus, that can result in sepsis spreading to surrounding organs, or pelvic infections.
Causes
By definition, septic abortion is caused by a variety of bacterial infections. Bacteria can come from vaginal and endocervical flora or can be transmitted sexually.
The development of sepsis is primarily due to two scenarios. When there is an incomplete abortion caused by the pathogens that result in products of conception remaining in the body. The second scenario occurs intentional septic procedures leads to the spread of the infection from the placenta or fetus to the uterus; this can subsequently cause pelvic septicamia. Possible pathogens include ''Neisseria gonorrhoeae, Chlamydia trachomatis, Escherichia coli, Mycoplasma hominis'', ''Clostridium perfringens, Klebsiella'' and ''Proteus'' species, staphylococcal strains, and other gram-positive or gram-negative bacteria.
In 2011, an analysis was done to determine if a pregnant woman should be screened for Group B Streptococcus which has been found to be a cause for many diseases including septic abortion. Within the large range of potential pathogens, in third world countries tetanus is the most common cause, while in the U.S. ''Clostridium perfringens'' is the most common cause especially in induced abortions.
In situations where intentional abortion is performed illegally or in impoverished countries, there is a higher risk of septic complications because it is likely that the procedure was performed by non-professionals in unhygienic settings, making way for more exposure to infectious bacteria.
Put in perspective, infection caused 62% of illegal abortion and 51% of miscarriages, however infection only caused 21% of deaths from legally performed septic abortions.
Epidemiology
From 2015-2017, approximately 73.3 million abortions occurred worldwide each year. Furthermore, data from 2010-2014 showed that around 45% of these abortions were unsafe abortions, where most of these unsafe abortions occurred in developing countries. In particular, it was estimated that over 50% of the unsafe abortions occurred in Asia, with most in south and central Asia, and Africa. Global data from a 2008 systematic analysis also estimated that complications from unsafe abortions accounted for 13% of all maternal deaths. Furthermore, in a retrospective case study, it was found that maternal mortality associated with septic abortion was approximately 19%; however a systematic review of global data is still needed.
Septic abortion is of highest prevalence in vulnerable populations living in resource-poor environments, with prevalence reaching as high as 86% in these populations.
Within such environments, the incidence of septic abortion is highest among teenagers, and in areas with restrictive abortion laws due to a higher utilization of illicit abortion procedures carried out by non-doctors due to the inherent barriers in obtaining abortion. Therefore, "societies with high fertility rate, low contraceptive usage, and legal obstacles to safe termination of pregnancy
" predisposes the society to a higher prevalence of septic abortion.
Nevertheless, although the incidence of septic abortion is highest among teenagers between the ages of 16 and 24 years, which constitutes two-thirds of the population affected by septic abortion, septic complications are still common in older married people who are assigned female at birth.
The epidemiology of septic abortion is therefore dictated by risk factors and barriers to safe abortion.
Signs and symptoms
Signs and symptoms related to septic abortion are mainly:
* High
fever
Fever, also referred to as pyrexia, is defined as having a body temperature, temperature above the human body temperature, normal range due to an increase in the body's temperature Human body temperature#Fever, set point. There is not a single ...
, usually above 101 °
F / 38
°C
The degree Celsius is the unit of temperature on the Celsius scale (originally known as the centigrade scale outside Sweden), one of two temperature scales used in the International System of Units (SI), the other being the Kelvin scale. The ...
* Chills
* Severe abdominal pain and/or cramping /or strong
perineal pressure
* Beginning miscarriage symptoms (heavy bleeding and or cramping) that suddenly stops and does not resume
* Prolonged or heavy
vaginal bleeding
Vaginal bleeding is any expulsion of blood from the vagina. This bleeding may originate from the uterus, vaginal wall, or cervix. Generally, it is either part of a normal menstrual cycle or is caused by hormonal or other problems of the reproductiv ...
* Foul-smelling
vaginal discharge
Vaginal discharge is a mixture of liquid, cells, and bacteria that lubricate and protect the vagina. This mixture is constantly produced by the cells of the vagina and cervix, and it exits the body through the vaginal opening. The composition, amou ...
* Backache or heavy back pressure
A cold or
urinary tract infection
A urinary tract infection (UTI) is an infection that affects part of the urinary tract. When it affects the lower urinary tract it is known as a bladder infection (cystitis) and when it affects the upper urinary tract it is known as a kidney ...
may mimic many of the symptoms.
As the condition becomes more serious, signs of
septic shock
Septic shock is a potentially fatal medical condition that occurs when sepsis, which is organ injury or damage in response to infection, leads to dangerously low blood pressure and abnormalities in cellular metabolism. The Third International Con ...
may appear, including:
* Low blood pressure (
hypotension
Hypotension is low blood pressure. Blood pressure is the force of blood pushing against the walls of the arteries as the heart pumps out blood. Blood pressure is indicated by two numbers, the systolic blood pressure (the top number) and the dias ...
)
* Low body temperature (
hypothermia
Hypothermia is defined as a body core temperature below in humans. Symptoms depend on the temperature. In mild hypothermia, there is shivering and mental confusion. In moderate hypothermia, shivering stops and confusion increases. In severe h ...
)
* Little or no urine output (
oliguria
Oliguria or hypouresis is the low output of urine specifically more than 80 ml/day but less than 400ml/day.Boon et al, Davidson's Principles & Practice of Medicine (20th Ed), p475 The decreased output of urine may be a sign of dehydration, kidney ...
)
* Respiratory distress (
dyspnea
Shortness of breath (SOB), also medically known as dyspnea (in AmE) or dyspnoea (in BrE), is an uncomfortable feeling of not being able to breathing, breathe well enough. The American Thoracic Society defines it as "a subjective experience of brea ...
and
labored breathing Labored respiration or labored breathing is an abnormal respiration characterized by evidence of increased effort to breathe, including the use of accessory muscles of respiration, stridor, grunting, or nasal flaring.
Classification
Labored breath ...
)
Septic shock
Septic shock is a potentially fatal medical condition that occurs when sepsis, which is organ injury or damage in response to infection, leads to dangerously low blood pressure and abnormalities in cellular metabolism. The Third International Con ...
may lead to
kidney failure
Kidney failure, also known as end-stage kidney disease, is a medical condition in which the kidneys can no longer adequately filter waste products from the blood, functioning at less than 15% of normal levels. Kidney failure is classified as eit ...
,
bleeding diathesis
In medicine (hematology), bleeding diathesis is an unusual susceptibility to bleed (hemorrhage) mostly due to hypocoagulability (a condition of irregular and slow blood clotting), in turn caused by a coagulopathy (a defect in the system of coagula ...
, and
disseminated intravascular coagulation
Disseminated intravascular coagulation (DIC) is a condition in which blood clots form throughout the body, blocking small blood vessels. Symptoms may include chest pain, shortness of breath, leg pain, problems speaking, or problems moving parts o ...
(DIC). Intestinal organs may also become infected, potentially causing scar tissue with chronic pain, intestinal blockage, and infertility.
If the septic abortion is not treated quickly and effectively, the woman may die.
Diagnosis
Septic abortion is diagnosed using clinical evaluation,
bacterial cultures, and
ultrasonography
Ultrasound is sound waves with frequencies higher than the upper audible limit of human hearing. Ultrasound is not different from "normal" (audible) sound in its physical properties, except that humans cannot hear it. This limit varies fr ...
on people who present with signs and symptoms with intrauterine infections following by an abortion within 20 weeks of gestation. Medical history and physical examination are used as the first line in identifying people who are suspected of having a septic abortion. A woman may present initially with a fever, ill appearance, abdominal pain, vaginal bleeding, trauma to the cervix and other potentially worrisome symptoms of an infection. Differential diagnosis of a septic abortion includes incomplete abortion with a cause of fever or spontaneous abortion with signs of inflammation redness of the lining of the uterus.
Clinical evaluation and lab test
Clinical findings are based on any infections ranging in severity in any patient presenting with fevers over 38 °C or 100.4 °F with severe abdominal pain and peritonitis, and foul smelling vaginal discharge.
A complete
blood count
A complete blood count (CBC), also known as a full blood count (FBC), is a set of medical laboratory tests that provide information about the cells in a person's blood. The CBC indicates the counts of white blood cells, red blood cells and pl ...
(CBC) with differential should be done in people with a fever to assess the presence of leukocytosis and brandemic which are the infection markers. Labs such as electrolyte levels, glucose,
blood urea nitrogen
Blood urea nitrogen (BUN) is a medical test that measures the amount of urea nitrogen found in blood. The liver produces urea in the urea cycle as a waste product of the digestion of protein. Normal human adult blood should contain 6 to 20 mg/dL ...
(BUN),
creatinine
Creatinine (; ) is a breakdown product of creatine phosphate from muscle and protein metabolism. It is released at a constant rate by the body (depending on muscle mass).
Biological relevance
Serum creatinine (a blood measurement) is an import ...
, liver function test (
LFT), antibody screening, lactate levels and coagulation studies such as
prothrombin time
The prothrombin time (PT) – along with its derived measures of prothrombin ratio (PR) and international normalized ratio (INR) – is an assay for evaluating the ''extrinsic'' pathway and common pathway of coagulation. This blood test is als ...
(PT), activated partial thromboplastin time (
aPTT
The partial thromboplastin time (PTT), also known as the activated partial thromboplastin time (aPTT or APTT), is a blood test that characterizes coagulation of the blood. A historical name for this measure is the kaolin-cephalin clotting time ( ...
) and fibrinogen should be looked at for any abnormalities especially with people with excessive bleeding.
Microbiology
individuals who are suspected to have a septic abortion, there are a few variations of
cultures
Culture () is an umbrella term which encompasses the social behavior, institutions, and norms found in human societies, as well as the knowledge, beliefs, arts, laws, customs, capabilities, and habits of the individuals in these groups.Tyl ...
that are taken for further diagnostic and treatment implications. Anaerobic bacterial, high vaginal, and cervical cultures can be used to identify the septic types and species of the offending microorganism. Primary organisms isolated are the non-clostridial anaerobic, microaerophilic bacteria, anaerobic streptococci. Group A of ''Beta haemolytic streptococci'' is the most pathogenic and is usually introduced into the genital tract externally as they are not normally found in the normal vaginal flora. Groups B and D are less virulent but it is also not found as the part of vaginal flora.
Table 1: pathogenic organisms in Septic Abortion
Ultrasonography and other Imaging Techniques
Ultrasonography, also known as "ultrasound", is often used following a clinical diagnosis to confirmed the specific location and the origin of a septic abortion.
Computed tomography (CT) or
magnetic resonance imaging
Magnetic resonance imaging (MRI) is a medical imaging technique used in radiology to form pictures of the anatomy and the physiological processes of the body. MRI scanners use strong magnetic fields, magnetic field gradients, and radio wave ...
(MRI) may be also used. Findings of a septic abortion include:
* An enlarged uterus with or without hemorrhage
* Intrauterine materials
* Free or unexpected fluid
* Formation of abscess
* Intrauterine air
Risk factors
The risk of post-abortion sepsis is increased by mainly the following factors:
*The
fetal membranes
The fetal membranes are the four extraembryonic membranes, associated with the developing embryo, and fetus in humans and other mammals.. They are the amnion, chorion, allantois, and yolk sac. The amnion and the chorion are the chorioamniotic memb ...
surrounding the fetus have ruptured, sometimes without being detected
* The woman has a
sexually transmitted infection
Sexually transmitted infections (STIs), also referred to as sexually transmitted diseases (STDs) and the older term venereal diseases, are infections that are Transmission (medicine), spread by Human sexual activity, sexual activity, especi ...
such as chlamydia
* An
intrauterine device
An intrauterine device (IUD), also known as intrauterine contraceptive device (IUCD or ICD) or coil, is a small, often T-shaped birth control device that is inserted into the uterus to prevent pregnancy. IUDs are one form of long-acting rever ...
(IUD) was left in place during the pregnancy
* Tissue from the fetus or placenta is left inside the uterus after a miscarriage or elective abortion procedure
* Insertion of tools, chemicals, or soaps into the uterus
* Undergoing septic abortion under illegal conditions (unsafe abortion)
* Undergoing septic abortion procedures in resource-poor areas (unsafe abortion)
* Incomplete septic abortion such as late uterine evacuation
* Delayed treatment
Complications
These are some of the complications that may occur especially if treatment is delayed:
*
Sepsis
Sepsis, formerly known as septicemia (septicaemia in British English) or blood poisoning, is a life-threatening condition that arises when the body's response to infection causes injury to its own tissues and organs. This initial stage is follo ...
*
Septic pelvic thrombophlebitis
Septic pelvic thrombophlebitis (SPT), also known as suppurative pelvic thrombophlebitis, is a rare postpartum complication which consists of a persistent postpartum fever that is not responsive to broad-spectrum antibiotics, in which pelvic infect ...
*Pelvic abscess (a build up of fluid in the fallopian tube, ovaries, or parametric tissue that is also infected with bacteria)
*Bacteraemia (a build up of bacteria in the blood stream)
*
Disseminated intravascular coagulopathy
Disseminated intravascular coagulation (DIC) is a condition in which blood clots form throughout the body, blocking small blood vessels. Symptoms may include chest pain, shortness of breath, leg pain, problems speaking, or problems moving parts o ...
*
Renal failure
Kidney failure, also known as end-stage kidney disease, is a medical condition in which the kidneys can no longer adequately filter waste products from the blood, functioning at less than 15% of normal levels. Kidney failure is classified as eit ...
*
Septic shock
Septic shock is a potentially fatal medical condition that occurs when sepsis, which is organ injury or damage in response to infection, leads to dangerously low blood pressure and abnormalities in cellular metabolism. The Third International Con ...
(most often caused by ''Clostridium welchii'' and ''Clostridium perfringens'')
* Death
Treatment
The woman should have
intravenous fluid
Intravenous therapy (abbreviated as IV therapy) is a medical technique that administers fluids, medications and nutrients directly into a person's vein. The intravenous route of administration is commonly used for rehydration or to provide nutrie ...
s to maintain blood pressure and urine output (
oliguria
Oliguria or hypouresis is the low output of urine specifically more than 80 ml/day but less than 400ml/day.Boon et al, Davidson's Principles & Practice of Medicine (20th Ed), p475 The decreased output of urine may be a sign of dehydration, kidney ...
or hypouresis are both names from roots meaning "not enough urine"; these terms refer to the low output of urine).
Broad-spectrum intravenous antibiotics should be given until the fever is gone. There are different antibiotic regimens which are almost equal such as intravenous
clindamycin
Clindamycin is an antibiotic medication used for the treatment of a number of bacterial infections, including osteomyelitis (bone) or joint infections, pelvic inflammatory disease, strep throat, pneumonia, acute otitis media (middle ear infec ...
,
penicillin
Penicillins (P, PCN or PEN) are a group of β-lactam antibiotics originally obtained from ''Penicillium'' moulds, principally '' P. chrysogenum'' and '' P. rubens''. Most penicillins in clinical use are synthesised by P. chrysogenum using ...
plus
chloramphenicol
Chloramphenicol is an antibiotic useful for the treatment of a number of bacterial infections. This includes use as an eye ointment to treat conjunctivitis. By mouth or by injection into a vein, it is used to treat meningitis, plague, cholera, a ...
,
cephalothin
Cefalotin (INN) or cephalothin (USAN) is a first-generation cephalosporin antibiotic. It was the first cephalosporin marketed (1964) and continues to be widely used. It is an intravenously administered agent with a similar antimicrobial spec ...
plus
kanamycin
Kanamycin A, often referred to simply as kanamycin, is an antibiotic used to treat severe bacterial infections and tuberculosis. It is not a first line treatment. It is used by mouth, injection into a vein, or injection into a muscle. Kanamycin ...
.
And only one research found that
tetracycline
Tetracycline, sold under various brand names, is an oral antibiotic in the tetracyclines family of medications, used to treat a number of infections, including Acne vulgaris, acne, cholera, brucellosis, plague (disease), plague, malaria, and sy ...
is more effective to decrease the time of fever than
penicillin G
Benzylpenicillin, also known as penicillin G (PenG) or BENPEN, and in military slang "Peanut Butter Shot" is an antibiotic used to treat a number of bacterial infections. This includes pneumonia, strep throat, syphilis, necrotizing enterocolitis ...
.
However, new studies are needed to establish the most effective antibiotic in septic abortion.
A
dilatation and curettage
Dilation (or dilatation) and curettage (D&C) refers to the dilation (widening/opening) of the cervix and surgical removal of part of the lining of the uterus and/or contents of the uterus by scraping and scooping (curettage). It is a gynecologic ...
(D&C) or
misoprostol
Misoprostol is a synthetic prostaglandin medication used to prevent and treat stomach and duodenal ulcers, induce labor, cause an abortion, and treat postpartum bleeding due to poor contraction of the uterus. Misoprostol is taken by mouth wh ...
may be needed to clean the uterus of any residual tissue.
Rh negative
The Rh blood group system is a human blood group system. It contains proteins on the surface of red blood cells. After the ABO blood group system, it is the most likely to be involved in transfusion reactions. The Rh blood group system consists ...
blood should be given to the woman in addition to an injection of Rh immune globulin, unless the father is also known to be Rh negative. In cases so severe that
abscess
An abscess is a collection of pus that has built up within the tissue of the body. Signs and symptoms of abscesses include redness, pain, warmth, and swelling. The swelling may feel fluid-filled when pressed. The area of redness often extends b ...
es have formed in the ovaries and tubes, it may be necessary to remove the uterus by
hysterectomy
Hysterectomy is the surgical removal of the uterus. It may also involve removal of the cervix, ovaries (oophorectomy), Fallopian tubes (salpingectomy), and other surrounding structures.
Usually performed by a gynecologist, a hysterectomy may b ...
, and possibly other infected organs as well.
After successful treatment of a septic abortion, a woman may be tired for several weeks. In case of substantial bleeding,
iron supplementation
Iron supplements, also known as iron salts and iron pills, are a number of iron formulations used to treat and prevent iron deficiency including iron deficiency anemia. For prevention they are only recommended in those with poor absorption, ...
may be helpful.
Sexual intercourse
Sexual intercourse (or coitus or copulation) is a sexual activity typically involving the insertion and thrusting of the penis into the vagina for sexual pleasure or reproduction.Sexual intercourse most commonly means penile–vaginal penetrat ...
or the use of tampons should be avoided until recommended by the healthcare provider.
Prevention
Primary prevention
Most complications and deaths associated with septic
abortion
Abortion is the termination of a pregnancy by removal or expulsion of an embryo or fetus. An abortion that occurs without intervention is known as a miscarriage or "spontaneous abortion"; these occur in approximately 30% to 40% of pregn ...
s can be prevented by reducing the chances of unwanted pregnancies through comprehensive sexual education and optimal use of effective
contraception
Birth control, also known as contraception, anticonception, and fertility control, is the use of methods or devices to prevent unwanted pregnancy. Birth control has been used since ancient times, but effective and safe methods of birth contr ...
s. Unwanted pregnancies can be avoided and reduced by improving social equality which would prevent women from
coercive
Coercion () is compelling a party to act in an involuntary manner by the use of threats, including threats to use force against a party. It involves a set of forceful actions which violate the free will of an individual in order to induce a desi ...
sexual relationships. A 2015
meta-analysis
A meta-analysis is a statistical analysis that combines the results of multiple scientific studies. Meta-analyses can be performed when there are multiple scientific studies addressing the same question, with each individual study reporting me ...
study showed that motivational interviewing on contraceptive use can increase the effective use of it immediately after interview and up to four months post-intervention. Another factor for preventing unsafe abortion is having access to safe, legal abortion services.
According to the
World Health Organization
The World Health Organization (WHO) is a specialized agency of the United Nations responsible for international public health. The WHO Constitution states its main objective as "the attainment by all peoples of the highest possible level of h ...
(WHO), 22 million unsafe abortions occur each year globally. Studies have shown that women appear to have low knowledge on abortion regulations and laws in their countries. In other words, the lack of knowledge on legal status of abortion can cause women to seek abortion services that are unsafe.
Systematic reviews
A systematic review is a scholarly synthesis of the evidence on a clearly presented topic using critical methods to identify, define and assess research on the topic. A systematic review extracts and interprets data from published studies on t ...
have shown that education on legal situation of abortion services and knowledge on accessible safe services would reduce the chance of women seeking for unsafe options that would lead to complications such as septic abortions.
Secondary prevention
Secondary prevention of septic abortions can be achieved by early detection and treatment of inflammation of the lining of the
uterus
The uterus (from Latin ''uterus'', plural ''uteri'') or womb () is the organ in the reproductive system of most female mammals, including humans that accommodates the embryonic and fetal development of one or more embryos until birth. The uter ...
that could prevent more serious infections. Initial assessments of patient's history, and symptoms can be helpful in understanding the severity of the problem. Physical exams and
pelvic exams as well as
blood culture
A blood culture is a medical laboratory test used to detect bacteria or fungi in a person's blood. Under normal conditions, the blood does not contain microorganisms: their presence can indicate a bloodstream infection such as bacteremia or f ...
s should be used to determine the main reason behind the infection. It has been found that variety of bacteria can lead to infected abortions and no one
antibiotic
An antibiotic is a type of antimicrobial substance active against bacteria. It is the most important type of antibacterial agent for fighting bacterial infections, and antibiotic medications are widely used in the treatment and prevention of ...
is preferred. Therefore, investigating blood cultures would be an important step to guide antibiotic therapy. Following up to date guidelines and well-studied treatment regimens is recommended.
Tertiary prevention
Tertiary prevention of septic abortion are approaches that minimize organ
disability
Disability is the experience of any condition that makes it more difficult for a person to do certain activities or have equitable access within a given society. Disabilities may be Cognitive disability, cognitive, Developmental disability, dev ...
or death risk from the infection. If the infection is not eradicated and managed, it can lead to septic shock and
acute respiratory distress syndrome
Acute respiratory distress syndrome (ARDS) is a type of respiratory failure characterized by rapid onset of widespread inflammation in the lungs. Symptoms include shortness of breath (dyspnea), rapid breathing (tachypnea), and bluish skin colo ...
(ARDS).
In severe cases, women with high fever,
pelvis peritonitis, and
tachycardia
Tachycardia, also called tachyarrhythmia, is a heart rate that exceeds the normal resting rate. In general, a resting heart rate over 100 beats per minute is accepted as tachycardia in adults. Heart rates above the resting rate may be normal (su ...
should be hospitalized for a course of antibiotic and evacuation of the remaining pregnancy tissue. If there is no response from emptying of the
uterus
The uterus (from Latin ''uterus'', plural ''uteri'') or womb () is the organ in the reproductive system of most female mammals, including humans that accommodates the embryonic and fetal development of one or more embryos until birth. The uter ...
, the patient could be indicated for another procedure called
laparotomy
A laparotomy is a surgical procedure involving a surgical incision through the abdominal wall to gain access into the abdominal cavity. It is also known as a celiotomy.
Origins and history
The first successful laparotomy was performed without ane ...
. finally, patients with severe sepsis may develop ARDS. In that case, blood
oxygen saturation
Oxygen saturation (symbol SO2) is a relative measure of the concentration of oxygen that is dissolved or carried in a given medium as a proportion of the maximal concentration that can be dissolved in that medium at the given temperature. It ca ...
should be monitored and adequate ventilation has to start if the saturation level drops below optimal levels.
References
{{reflist
Health issues in pregnancy