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 epithelium, 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 funct ...

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 pregn ...

. The genital tract during this period is particularly vulnerable to infection, and

sepsis Sepsis is a potentially life-threatening condition that arises when the body's response to infection causes injury to its own tissues and organs. This initial stage of sepsis is followed by suppression of the immune system. Common signs and s ...

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 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. 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 98% 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. Especially considering the emergence of antibiotic resistant bacteria, septic abortions are of high concern for the medical community.

Signs and symptoms

Signs and symptoms related to septic abortion are mainly: * High

fever Fever or pyrexia in humans is a symptom of an anti-infection defense mechanism that appears with Human body temperature, body temperature exceeding the normal range caused by an increase in the body's temperature Human body temperature#Fever, s ...

, usually above 101 ° F / 38

°C The degree Celsius is the unit of temperature on the Celsius temperature scale "Celsius temperature scale, also called centigrade temperature scale, scale based on 0 ° for the melting point of water and 100 ° for the boiling point ...

* 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, ...

* Backache or heavy back pressure A cold or

urinary tract infection A urinary tract infection (UTI) is an infection that affects a part of the urinary tract. Lower urinary tract infections may involve the bladder (cystitis) or urethra (urethritis) while upper urinary tract infections affect the kidney (pyel ...

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 C ...

may appear, including: * Low blood pressure (

hypotension Hypotension, also known as low blood pressure, is a cardiovascular condition characterized by abnormally reduced blood pressure. Blood pressure is the force of blood pushing against the walls of the arteries as the heart pumps out blood and is ...

) * 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 ...

) * 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. The decreased output of urine may be a sign of dehydration, kidney failure, hypovolemic shock, hyperosmolar Hyperglycemic Nonketotic Syndro ...

) * Respiratory distress (

dyspnea Shortness of breath (SOB), known as dyspnea (in AmE) or dyspnoea (in BrE), is an uncomfortable feeling of not being able to breathe well enough. The American Thoracic Society defines it as "a subjective experience of breathing discomfort that ...

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 br ...

)

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 C ...

may lead to

kidney failure Kidney failure, also known as renal failure or end-stage renal disease (ESRD), 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 fa ...

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 coagul ...

, and

disseminated intravascular coagulation Disseminated intravascular coagulation (DIC) is a condition in which blood clots form throughout the body, blocking Microvessel, small blood vessels. Symptoms may include chest pain, shortness of breath, leg pain, problems speaking, or problems ...

(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 Medical ultrasound includes diagnostic techniques (mainly imaging) using ultrasound, as well as therapeutic applications of ultrasound. In diagnosis, it is used to create an image of internal body structures such as tendons, muscles, joints, ...

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) or full haemogram (FHG), is a set of medical laboratory tests that provide cytometry, information about the cells in a person's blood. The CBC indicates the counts of white blo ...

(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 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 impor ...

, 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 Coagulation#Extrinsic pathway, extrinsic pathway and Coagulation#Common pathway, ...

(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

In individuals who are suspected to have a septic abortion, there are a few variations of

cultures Culture ( ) is a concept that encompasses the social behavior, institutions, and Social norm, norms found in human societies, as well as the knowledge, beliefs, arts, laws, Social norm, customs, capabilities, Attitude (psychology), attitudes ...

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 A computed tomography scan (CT scan), formerly called computed axial tomography scan (CAT scan), is a medical imaging technique used to obtain detailed internal images of the body. The personnel that perform CT scans are called radiographers or ...

(CT) or

magnetic resonance imaging Magnetic resonance imaging (MRI) is a medical imaging technique used in radiology to generate pictures of the anatomy and the physiological processes inside the body. MRI scanners use strong magnetic fields, magnetic field gradients, and ...

(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 ...

surrounding the fetus have ruptured, sometimes without being detected * The woman has a

sexually transmitted infection A sexually transmitted infection (STI), also referred to as a sexually transmitted disease (STD) and the older term venereal disease (VD), is an infection that is Transmission (medicine), spread by Human sexual activity, sexual activity, e ...

such as chlamydia * An

intrauterine device An intrauterine device (IUD), also known as an 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 a 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 is a potentially life-threatening condition that arises when the body's response to infection causes injury to its own tissues and organs. This initial stage of sepsis is followed by suppression of the immune system. Common signs and s ...

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 ...

Renal failure Kidney failure, also known as renal failure or end-stage renal disease (ESRD), 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 fa ...

(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 nutr ...

s to maintain blood pressure and urine output (

or hypouresis are both names from roots meaning "not enough urine"; these terms refer to the low output of urine).

Broad-spectrum A broad-spectrum antibiotic is an antibiotic that acts on the two major bacterial groups, Gram-positive and Gram-negative, or any antibiotic that acts against a wide range of disease-causing bacteria. These medications are used when a bacterial in ...

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 a lincosamide 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 (mi ...

penicillin Penicillins (P, PCN or PEN) are a group of beta-lactam antibiotic, β-lactam antibiotics originally obtained from ''Penicillium'' Mold (fungus), moulds, principally ''Penicillium chrysogenum, P. chrysogenum'' and ''Penicillium rubens, P. ru ...

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 intravenous, injection into a vein, it is used to treat meningitis, pl ...

cephalothin Cefalotin (INN) or cephalothin ( USAN) is a first-generation cephalosporin antibiotic with broad spectrum antibiotic activity. It was the first cephalosporin marketed (1964) and continues to be widely used. Cefalotin is used for bacterial infe ...

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. Kanamy ...

. And only one research found that

tetracycline Tetracycline, sold under various brand names, is an antibiotic in the tetracyclines family of medications, used to treat a number of infections, including acne, cholera, brucellosis, plague, malaria, and syphilis. It is available in oral an ...

is more effective to decrease the time of fever than

penicillin G Benzylpenicillin, also known as penicillin G (PenG) or BENPEN, is an antibiotic used to treat a number of bacterial infections. This includes pneumonia, strep throat, syphilis, necrotizing enterocolitis, diphtheria, gas gangrene, leptospiros ...

. However, new studies are needed to establish the most effective antibiotic in septic abortion. A

dilatation and curettage Dilation (or dilatation) may refer to: Physiology or medicine * Cervical dilation, the widening of the cervix in childbirth, miscarriage etc. * Coronary dilation, or coronary reflex * Dilation and curettage, the opening of the cervix and surg ...

(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. It is taken by mouth when used ...

may be ultilized to clean the uterus of any residual tissue.Eschenbach, David A. MD. Treating Spontaneous and Induced Septic Abortions. Obstetrics & Gynecology 125(5):p 1042-1048, May 2015. ,

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 most likely to be involved in transfusion reactions. The Rh blood group system consisted of ...

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. In cases so severe that

abscess An abscess is a collection of pus that has built up within the tissue of the body, usually caused by bacterial infection. Signs and symptoms of abscesses include redness, pain, warmth, and swelling. The swelling may feel fluid-filled when pre ...

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 and cervix. Supracervical hysterectomy refers to removal of the uterus while the cervix is spared. These procedures may also involve removal of the ovaries (oophorectomy), fallopian tubes ( salpi ...

, 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 Sexual intercourse (also coitus or copulation) is a sexual activity typically involving the insertion of the Erection, erect male Human penis, penis inside the female vagina and followed by Pelvic thrust, thrusting motions for sexual pleasure ...

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 early termination of a pregnancy by removal or expulsion of an embryo or fetus. Abortions that occur without intervention are known as miscarriages or "spontaneous abortions", and occur in roughly 30–40% of all pregnan ...

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 pregnancy. Birth control has been used since ancient times, but effective and safe methods of birth control only be ...

s. Unwanted pregnancies can be avoided and reduced by improving social equality which would prevent women from

coercive Coercion involves compelling a party to act in an involuntary manner through the use of threats, including threats to use force against that party. It involves a set of forceful actions which violate the free will of an individual in order to in ...

sexual relationships. A 2015

meta-analysis Meta-analysis is a method of synthesis of quantitative data from multiple independent studies addressing a common research question. An important part of this method involves computing a combined effect size across all of the studies. As such, th ...

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, and comprehensive abortion services. According to the

World Health Organization The World Health Organization (WHO) is a list of specialized agencies of the United Nations, specialized agency of the United Nations which coordinates responses to international public health issues and emergencies. It is headquartered in Gen ...

(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 ...

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'', : uteri or uteruses) or womb () is the hollow organ, organ in the reproductive system of most female mammals, including humans, that accommodates the embryonic development, embryonic and prenatal development, f ...

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 ...

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 pathogenic bacteria, bacterial infections, and antibiotic medications are widely used in the therapy ...

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, d ...

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 co ...

(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 ...

should be hospitalized for a course of antibiotic and evacuation of the remaining pregnancy tissue. If there is no response from emptying of the

, 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 ...

. 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 Dissolution (chemistry), dissolved or carried in a given medium as a proportion of the maximal concentration that can be dissolved in that medium at the g ...

should be monitored and adequate ventilation has to start if the saturation level drops below optimal levels.

References

{{reflist Health issues in pregnancy