Septic abortion

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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 during or after 20 weeks of gestation. [1] The genital tract during this period is particularly vulnerable to infection, and sepsis in most cases is caused by a combination of factors both due to facility conditions and/or individual predispositions. [2] 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. [3]

Contents

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. [4] 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 septicaemia. 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. [5] 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. [6] 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. [4] 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. [5] 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. [7]

Epidemiology

From 2015-2017, approximately 73.3 million abortions occurred worldwide each year. [8] Furthermore, data from 2010-2014 showed that around 45% of these abortions were unsafe abortions, where 98% of these unsafe abortions occurred in developing countries. [9] In particular, it was estimated that over 50% of the unsafe abortions occurred in Asia, with most in south and central Asia, and Africa. [10] Global data from a 2008 systematic analysis also estimated that complications from unsafe abortions accounted for 13% of all maternal deaths. [11] Furthermore, in a retrospective case study, it was found that maternal mortality associated with septic abortion was approximately 19%; [12] 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. [5] 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 [5] " 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. [5] The epidemiology of septic abortion is therefore dictated by risk factors and barriers to safe abortion.

Especially considering the emergence of antibiotic resistant bacteria, septic abortions are of high concern for the medical community. [13]

Signs and symptoms

Signs and symptoms related to septic abortion are mainly: [3] [14]

A cold or urinary tract infection may mimic many of the symptoms.

As the condition becomes more serious, signs of septic shock may appear, including:

Septic shock may lead to kidney failure, bleeding diathesis, and disseminated intravascular coagulation (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 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. [3]

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. [14] A complete blood count (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 (BUN), creatinine, liver function test (LFT), antibody screening, lactate levels and coagulation studies such as prothrombin time (PT), activated partial thromboplastin time (aPTT) and fibrinogen should be looked at for any abnormalities especially with people with excessive bleeding. [15]

Microbiology

In individuals who are suspected to have a septic abortion, there are a few variations of cultures 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. [16] 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. [17]

Table 1: pathogenic organisms in Septic Abortion

AnaerobicAerobic
Bacteroides fragilis

Bacteroides melaninogenicus

Peptostreptococcus species

Peptococcus species

Fusobacterium species

Clostridium perfringens

Clostridium tetani

Escherichia coli

Enterobacter species

Beta haemolytic streptococci

Proteus species

Klebsiella aerogenes

Pseudomonas aeruginosa

Neisseria gonorrhoeae

Staphylococcus aureus

Streptococcus milleri

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. [18] Computed tomography (CT) or magnetic resonance imaging (MRI) may be also used. Findings of a septic abortion include: [19]

Risk factors

The risk of post-abortion sepsis is increased by mainly the following factors: [7] [20]

Complications

These are some of the complications that may occur especially if treatment is delayed: [21]

Treatment

The woman should have intravenous fluids to maintain blood pressure and urine output (oliguria 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, penicillin plus chloramphenicol, cephalothin plus kanamycin. [1] And only one research found that tetracycline is more effective to decrease the time of fever than penicillin G. [1] However, new studies are needed to establish the most effective antibiotic in septic abortion. [1]

A dilatation and curettage (D&C) or misoprostol may be ultilized to clean the uterus of any residual tissue. [25] Rh negative 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. The removal of the infected tissue is often one of the most effective treatments for septic abortion. [25] In cases so severe that abscesses have formed in the ovaries and tubes, it may be necessary to remove the uterus by hysterectomy, 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 may be helpful. Sexual intercourse or the use of tampons should be avoided until recommended by the healthcare provider.

Prevention

Primary prevention

Most complications and deaths associated with septic abortions can be prevented by reducing the chances of unwanted pregnancies through comprehensive sexual education and optimal use of effective contraceptions. [26] Unwanted pregnancies can be avoided and reduced by improving social equality which would prevent women from coercive sexual relationships. A 2015 meta-analysis 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. [27] Another factor for preventing unsafe abortion is having access to safe, legal, and comprehensive abortion services. [28] [29] According to the World Health Organization (WHO), 22 million unsafe abortions occur each year globally. [30] 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 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. [31]

Secondary prevention

Secondary prevention of septic abortions can be achieved by early detection and treatment of inflammation of the lining of the uterus that could prevent more serious infections. Initial assessments of patient's history, and symptoms can be helpful in understanding the severity of the problem. [32] Physical exams and pelvic exams as well as blood cultures 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 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. [33]

Tertiary prevention

Tertiary prevention of septic abortion are approaches that minimize organ disability 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 (ARDS). [28] In severe cases, women with high fever, pelvis peritonitis, and tachycardia 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 patient could be indicated for another procedure called laparotomy. [34] finally, patients with severe sepsis may develop ARDS. In that case, blood oxygen saturation should be monitored and adequate ventilation has to start if the saturation level drops below optimal levels. [35]

Related Research Articles

Dilationand curettage (D&C) refers to the dilation of the cervix and surgical removal of sections and/or layers of the lining of the uterus and or contents of the uterus such as an unwanted fetus, remains of a non-viable fetus, retained placenta after birth or abortion as well as any abnormal tissue which may be in the uterus causing abnormal cycles by scraping and scooping (curettage). It is a gynecologic procedure used for treatment and removal as well as diagnostic and therapeutic purposes, and is the most commonly used method for first trimester abortion or miscarriage.

<span class="mw-page-title-main">Pelvic inflammatory disease</span> Infection of uterus, fallopian tubes, ovaries or the inner surface of pelvis

Pelvic inflammatory disease, also known as pelvic inflammatory disorder (PID), is an infection of the upper part of the female reproductive system, mainly the uterus, fallopian tubes, and ovaries, and inside of the pelvis. Often, there may be no symptoms. Signs and symptoms, when present, may include lower abdominal pain, vaginal discharge, fever, burning with urination, pain with sex, bleeding after sex, or irregular menstruation. Untreated PID can result in long-term complications including infertility, ectopic pregnancy, chronic pelvic pain, and cancer.

<span class="mw-page-title-main">Maternal death</span> Aspect of human reproduction and medicine

Maternal death or maternal mortality is defined in slightly different ways by several different health organizations. The World Health Organization (WHO) defines maternal death as the death of a pregnant mother due to complications related to pregnancy, underlying conditions worsened by the pregnancy or management of these conditions. This can occur either while she is pregnant or within six weeks of resolution of the pregnancy. The CDC definition of pregnancy-related deaths extends the period of consideration to include one year from the resolution of the pregnancy. Pregnancy associated death, as defined by the American College of Obstetricians and Gynecologists (ACOG), are all deaths occurring within one year of a pregnancy resolution. Identification of pregnancy associated deaths is important for deciding whether or not the pregnancy was a direct or indirect contributing cause of the death.

A pessary is a prosthetic device inserted into the vagina for structural and pharmaceutical purposes. It is most commonly used to treat stress urinary incontinence to stop urinary leakage and to treat pelvic organ prolapse to maintain the location of organs in the pelvic region. It can also be used to administer medications locally in the vagina or as a method of contraception.

<span class="mw-page-title-main">Postpartum infections</span> Human disease

Postpartum infections, also known as childbed fever and puerperal fever, are any bacterial infections of the female reproductive tract following childbirth or miscarriage. Signs and symptoms usually include a fever greater than 38.0 °C (100.4 °F), chills, lower abdominal pain, and possibly bad-smelling vaginal discharge. It usually occurs after the first 24 hours and within the first ten days following delivery.

<span class="mw-page-title-main">Vaginal bleeding</span> Medical condition

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 reproductive system, such as abnormal uterine bleeding.

<span class="mw-page-title-main">Unsafe abortion</span> Termination of a pregnancy by using unsafe methods

An unsafe abortion is the termination of a pregnancy by people lacking the necessary skills, or in an environment lacking minimal medical standards, or both. An unsafe abortion is a life-threatening procedure. It includes self-induced abortions, abortions in unhygienic conditions, and abortions performed by a medical practitioner who does not provide appropriate post-abortion attention. About 25 million unsafe abortions occur a year, of which most occur in the developing world.

<span class="mw-page-title-main">Prelabor rupture of membranes</span> Breakage of the amniotic sac before the onset of labour

Prelabor rupture of membranes (PROM), previously known as premature rupture of membranes, is breakage of the amniotic sac before the onset of labour. Women usually experience a painless gush or a steady leakage of fluid from the vagina. Complications in the baby may include premature birth, cord compression, and infection. Complications in the mother may include placental abruption and postpartum endometritis.

<span class="mw-page-title-main">Complications of pregnancy</span> Medical condition

Complications of pregnancy are health problems that are related to, or arise during pregnancy. Complications that occur primarily during childbirth are termed obstetric labor complications, and problems that occur primarily after childbirth are termed puerperal disorders. While some complications improve or are fully resolved after pregnancy, some may lead to lasting effects, morbidity, or in the most severe cases, maternal or fetal mortality.

<span class="mw-page-title-main">Uterine artery embolization</span>

Uterine artery embolization is a procedure in which an interventional radiologist uses a catheter to deliver small particles that block the blood supply to the uterine body. The procedure is primarily done for the treatment of uterine fibroids and adenomyosis. Compared to surgical treatment for fibroids such as a hysterectomy, in which a woman's uterus is removed, uterine artery embolization may be beneficial in women who wish to retain their uterus. Other reasons for uterine artery embolization are postpartum hemorrhage and uterine arteriovenous malformations.

<span class="mw-page-title-main">Endometritis</span> Medical condition

Endometritis is inflammation of the inner lining of the uterus (endometrium). Symptoms may include fever, lower abdominal pain, and abnormal vaginal bleeding or discharge. It is the most common cause of infection after childbirth. It is also part of spectrum of diseases that make up pelvic inflammatory disease.

<span class="mw-page-title-main">Chorioamnionitis</span> Medical condition

Chorioamnionitis, also known as amnionitis and intra-amniotic infection (IAI), is inflammation of the fetal membranes, usually due to bacterial infection. In 2015, a National Institute of Child Health and Human Development Workshop expert panel recommended use of the term "triple I" to address the heterogeneity of this disorder. The term triple I refers to intrauterine infection or inflammation or both and is defined by strict diagnostic criteria, but this terminology has not been commonly adopted although the criteria are used.

<span class="mw-page-title-main">Vaginal delivery</span> Delivery through the vagina

A vaginal delivery is the birth of offspring in mammals through the vagina. It is the most common method of childbirth worldwide. It is considered the preferred method of delivery, as it is correlated with lower morbidity and mortality than caesarean sections (C-sections), though it is not clear whether this is causal.

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 infection leads to infection of the vein wall and intimal damage leading to thrombogenesis in the ovarian veins. The thrombus is then invaded by microorganisms. Ascending infections cause 99% of postpartum SPT.

<span class="mw-page-title-main">Postcoital bleeding</span> Non-menstrual vaginal bleeding during or after sexual intercourse

Postcoital bleeding (PCB) is non-menstrual vaginal bleeding that occurs during or after sexual intercourse. Though some causes are with associated pain, it is typically painless and frequently associated with intermenstrual bleeding.

Early pregnancy bleeding is vaginal bleeding before 14 weeks of gestational age. If the bleeding is significant, hemorrhagic shock may occur. Concern for shock is increased in those who have loss of consciousness, chest pain, shortness of breath, or shoulder pain.

<span class="mw-page-title-main">Tubo-ovarian abscess</span> One of the late complications of pelvic inflammatory disease

A tubo-ovarian abscess (TOA) is one of the late complications of pelvic inflammatory disease (PID) and can be life-threatening if the abscess ruptures and results in sepsis. It consists of an encapsulated or confined pocket of pus with defined boundaries that forms during an infection of a fallopian tube and ovary. These abscesses are found most commonly in reproductive age women and typically result from upper genital tract infection. It is an inflammatory mass involving the fallopian tube, ovary and, occasionally, other adjacent pelvic organs. A TOA can also develop as a complication of a hysterectomy.

The exact role of Mycoplasma hominis in regards to a number of conditions related to pregnant women and their (unborn) offspring is controversial. This is mainly because many healthy adults have genitourinary colonization with Mycoplasma, published studies on pathogenicity have important design limitations and the organisms are very difficult to detect. The likelihood of colonization with M. hominis appears directly linked to the number of lifetime sexual partners Neonatal colonization does occur, but only through normal vaginal delivery. Caesarean section appears protective against colonization and is much less common. Neonatal colonization is transient.

<span class="mw-page-title-main">Neonatal infection</span> Human disease

Neonatal infections are infections of the neonate (newborn) acquired during prenatal development or within the first four weeks of life. Neonatal infections may be contracted by mother to child transmission, in the birth canal during childbirth, or after birth. Neonatal infections may present soon after delivery, or take several weeks to show symptoms. Some neonatal infections such as HIV, hepatitis B, and malaria do not become apparent until much later. Signs and symptoms of infection may include respiratory distress, temperature instability, irritability, poor feeding, failure to thrive, persistent crying and skin rashes.

Pelvic abscess is a collection of pus in the pelvis, typically occurring following lower abdominal surgical procedures, or as a complication of pelvic inflammatory disease (PID), appendicitis, or lower genital tract infections. Signs and symptoms include a high fever, pelvic mass, vaginal bleeding or discharge, and lower abdominal pain. It can lead to sepsis and death.

References

  1. 1 2 3 4 Udoh, Atim; Effa, Emmanuel E; Oduwole, Olabisi; Okusanya, Babasola O; Okafo, Obiamaka (2016). "Antibiotics for treating septic abortion". The Cochrane Database of Systematic Reviews. 2016 (7): CD011528. doi:10.1002/14651858.CD011528.pub2. ISSN   1469-493X. PMC   6458041 . PMID   27364644.
  2. ↑ Stabile, Isabel (1992). Spontaneous Abortion : Diagnosis and Treatment. J. G. Grudzinskas, T. Chard. London: Springer London. ISBN   978-1-4471-1918-0. OCLC   853269541.
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  28. 1 2 Grimes, David A.; Benson, Janie; Singh, Susheela; Romero, Mariana; Ganatra, Bela; Okonofua, Friday E.; Shah, Iqbal H. (2006-11-25). "Unsafe abortion: the preventable pandemic". The Lancet. 368 (9550): 1908–1919. doi:10.1016/S0140-6736(06)69481-6. ISSN   0140-6736. PMID   17126724. S2CID   6188636.
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  32. ↑ Ashworth, Felicity (1992), "Septic Abortion", Spontaneous Abortion, London: Springer London, pp. 119–132, doi: 10.1007/978-1-4471-1918-0_8 , ISBN   978-1-4471-1920-3
  33. ↑ Gao, Hongmei; Evans, Timothy W; Finney, Simon J (2008). "Bench-to-bedside review: Sepsis, severe sepsis and septic shock – does the nature of the infecting organism matter?". Critical Care. 12 (3): 212. doi: 10.1186/cc6862 . ISSN   1364-8535. PMC   2481435 . PMID   18466647.
  34. ↑ Sreelakshmi, U.; Thejaswini, J.; Bharathi, T. (August 2014). "The Outcome of Septic Abortion: A Tertiary Care Hospital Experience". The Journal of Obstetrics and Gynecology of India. 64 (4): 265–269. doi:10.1007/s13224-014-0509-4. ISSN   0971-9202. PMC   4126947 . PMID   25136172.
  35. ↑ Silversides, Jonathan A.; Major, Emmet; Ferguson, Andrew J.; Mann, Emma E.; McAuley, Daniel F.; Marshall, John C.; Blackwood, Bronagh; Fan, Eddy (2016-10-12). "Conservative fluid management or deresuscitation for patients with sepsis or acute respiratory distress syndrome following the resuscitation phase of critical illness: a systematic review and meta-analysis". Intensive Care Medicine. 43 (2): 155–170. doi:10.1007/s00134-016-4573-3. ISSN   0342-4642. PMID   27734109. S2CID   9366377.
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