Management

PRIMARY PREVENTION OF SEPTIC ABORTION

Primary prevention avoids the occurrence of disease or injury.

Includes:

o access to effective and acceptable contraception;

o access to safe, legal abortion in case of contraceptive failure (Not

applicable to Philippines because Abortion is Illegal as per Penal
Code of 1930) ;

o and appropriate medical management of abortion.

SECONDARY PREVENTION OF SEPTIC ABORTION

Secondary prevention requires:

early detection and treatment

prompt diagnosis and effective treatment of endometritis to

avoid more serious infections

Goal: halting the disease process.

Suspect septic abortion if:

any reproductive-age woman presents with vaginal bleeding,

lower abdominal pain, and fever.

Deaths from septic abortion:

usually due to delaymay lead to death: young or unmarried

women often conceal the abortion and delay seeking help until
moribund.
 a sensitive pregnancy test (capable of detecting 2050 mIU/mL
of beta-human chorionic gonadotropin [beta-hCG]) will usually be
positive.

o it takes 46 weeks for beta-hCG to become undetectable

after complete uterine evacuation.

Rapid initial assessment:

o to determine the severity of the problem.

o If the patient has been symptomatic for several days, more

generalized, serious illness may be present.

o Risk of perforation due to illegal abortion by insertion of rigid

foreign objects.

o Intrauterine instillation of soaps poses a special hazard for

uterine necrosis and renal failure.

On Physical Assessment, determine the following:

note abdominal tenderness, guarding, and rebound, and whether

tenderness is limited to the lower abdomen (pelvic peritonitis) or
is present over the entire abdomen (generalized peritonitis).

Are vaginal or cervical lacerations present?

Is there a foul odor?

Are products of conception or pus visible in the cervical os?

Is the uterus enlarged and tender?

Is there an adnexal mass?

If there is suspicion of perforation, do radiographic studies of the

abdomen to help identify free air or foreign bodies.
Women with mild illness, present with a triad of symptoms:

low-grade fever

mild lower abdominal pain

moderate vaginal bleeding.

Patients presenting with these symptoms usually have either

incomplete or failed abortion (continuing pregnancy) or hematometra
(retained clotted and liquid blood).

Ideal management is immediate re-evacuation of uterine

content.

accomplished safely and humanely by vacuum curettage with

local anesthesia and intravenous sedation.

The bacteriology of septic abortion

usually polymicrobial, derived from the normal flora of the vagina

and endocervix, with the important addition of sexually
transmitted pathogens.

Gram-positive and gram-negative aerobes and facultative or

obligate anaerobes

o Neisseria gonorrhoeae, and Chlamydia trachomatis are

possible pathogens.8

In the US, Clostridium perfringens and Clostridium sordellii

In developing countries, Clostridium tetani contributes to septic

abortion death.

Antibiotic of choice:

Because of the variety of bacterial agents found in infected

abortions, no one antibiotic agent is ideal.
 The recommended regimens of the Centers for Disease
Control and Prevention for outpatient management of
pelvic inflammatory disease are appropriate for patients with
early postabortal infection limited to the uterine cavity in
addition to uterine evacuation.

o ceftriaxone 250 mg by intramuscular injection (or other

third generation cephalosporin such as cefoxitin,
ceftizoxime, or cefotaxime) plus

o doxycycline 100 mg orally twice a day for 14 days, with

or without metronidazole 500 mg orally twice a day for
14 days.

o Quinolone: no longer first choice for outpatient

management of pelvic inflammatory disease in the US.

Principles of management:

o aggressive source control with antibiotics

o early hemodynamic resuscitation.

Management of severe sepsis:

o Eradicating the infection

Blood, urine, and cervical cultures
high-dose broad-spectrum IV antibiotics.
penicillin (5 million unitsIv every 6 hours)
or ampicillin (2 g IV every 6 hours) with
gentamicin (2 mg/kg loading dose, followed by
1.5 mg/kg every 8 hours or 5 mg/kg every 24
hour.)
Either clindamycin (900 mg IV every 8 hours)
or metranidazole (15 mg/kg initially followed by
7.5 mg/kg every 8 hours) is added.
 An endometrial biopsy specimen or tissue obtained
at uterine aspiration provides a better specimen for
culture than does cervical discharge. Examination of
the gram-stained material can guide early
management.
Rapid administration of broad-spectrum antibiotics is
key to ensuring a favorable outcome.

Emptying the uterus

o Evacuate remaining pregnancy tissue without delay as soon as

antibiotic therapy and fluid resuscitation are begun.

o Vacuum curettage is readily accomplished with the patient under

local anesthesia with minimal intravenous sedation.

o Medical uterine evacuation:

o Oxytocin:

50 units in 500 mL of 5% dextrose and normal saline

solution over a 3-hour period (approximately 278
mU/min).

followed by a 1-hour rest and repeated, adding 50

additional units to the next 500-mL infusion,

continue with 3 hours of infusion and 1 hour of rest.

This is repeated until the patient aborts or a final
solution of 300 U oxytocin in 500 mL is reached
(1667 mU/min).

o Metreurynter: A Foley catheter is placed in the lower uterus

and the balloon inflated to 5075 mL plus 1 kg of traction
to dilate cervix.

Indications for Laparotomy:

 o If patient does not respond to uterine evacuation and adequate
medical therapy.

o uterine perforation with suspected bowel injury, pelvic abscess,

and clostridial myometritis.

Indications for hysterectomy:

o critically ill women with severe postabortal sepsis, plus drainage

of any abscess.

Indications for total hysterectomy and possible removal of

bilateral adnexae:

o A discolored, woody appearance of the uterus and adnexa,

suspected clostridial sepsis, crepitation in the pelvic tissues, and
radiographic evidence of air within the uterine wall.

o Copious irrigation of purulent material and drainage of the

peritoneal cavity with closed suction systems is advised.
Diversion of the fecal stream by enterostomy is needed if there
is bowel injury.

TERTIARY PREVENTION OF SEPTIC ABORTION

minimizes the harm done by disease and avoids disability.

seeks to avoid serious consequences of infection, including

hysterectomy and death.

Systemic inflammatory response syndrome (SIRS) is the manifestation

of inflammatory response.

characterized by

fever >38C
 tachycardia >90 bpm

tachypnea RR >20

white blood cell count >12,000 or <4000, or >10% immature

forms.

Septic shock includes SIRS plus a suspected or present infection.

Severe sepsis includes SIRS plus evidence of organ

dysfunction.evidence of organ dysfunction in the setting of bacteremia.

Septic shock is suggested by:

tachycardia (>110)

respiratory distress

oliguria

altered mental status

hypotension despite adequate fluid resusitation.

Hospitalization:

for patients with more established infection, as indicated by:

o temperature elevation (>38C)

o pelvic peritonitis, or more severe disease,

parenteral antibiotic therapy and prompt uterine evacuation.

Sequalae of Septic abortion:

 Bacteremia is more common with septic abortion than with other
pelvic infections:

o septic shock and adult respiratory distress syndrome

(ARDS) may result.