The two most common complications associated with spontaneous abortion are hemorrhage and infection. Septic abortion occurs in 1% to 2% of all spontaneous abortions and about 0.5% of induced abortions. This risk is increased if an abortion is performed with nonsterile instrumentation. This condition is potentially fatal in 0.4 to 0.6/100 000 spontaneous abortions.

Signs and symptoms of septic abortion are uterine bleeding and/or spotting in the first trimester with clinical signs of infection. The infection ascends from the vagina or cervix to the endometrium to myometrium to parametrium, and, eventually, the peritoneum. Affected women generally will have fever and leukocyte counts of >10 500 cells/μL. There is usually lower abdominal tenderness, cervical motion tenderness, and a foul-smelling vaginal discharge. The infection is almost always polymicrobial, involving anaerobic streptococci, bacteroidesspecies, Escherichia coli and other gram-negative rods, and group B β-hemolytic streptococci. Rarely, Clostridium perfringensHemophilusinfluenzae, and Campylobacter jejuni may be isolated.

When patients present with signs and symptoms of septic abortion, a CBC with differential, urinalysis, and blood chemistries including electrolytes should be obtained. A specimen of cervical discharge should be sent for Gram stain, as well as for culture and sensitivity. If the patient appears seriously ill or is hypotensive, blood cultures, a chest x-ray, and blood coagulability studies should be done. The blood pressure, oxygen saturation, heart rate, and urine output should be monitored.

The treatment has four general parts: (1) maintain the blood pressure; (2) monitor the blood pressure, oxygenation, and urine output; (3) start antibiotic therapy; and (4) perform a uterine curettage. Immediate therapeutic steps include intravenous isotonic fluid replacement, especially in the face of hypotension. Concurrently, intravenous broad-spectrum antibiotics with particular attention to anaerobic coverage should be infused. The combination of gentamicin and clindamycin has a favorable response 95% of the time. Alternatives include β-lactam antimicrobials (cephalosporins and extended-spectrum penicillins) or those with β-lactamase inhibitors. Another regimen includes metronidazole plus ampicillin and an aminoglycoside. Because retained POC are common in these situations, becoming a nidus for infection to develop, evacuation of the uterine contents is important. Uterine curettage is usually performed approximately 4 hours after antibiotics are begun, allowing serum levels to be achieved. If patient does not respond to curettage and antibiotic treatment, a hysterectomy can be the next step in controlling the source of infection. Currently, no evidence has shown that a full antibiotic course is required if the patient remains afebrile for 48 hours post-D&C.

Because oliguria is an early sign of septic shock, the urine output should be carefully observed. Also, for women in shock, a central venous pressure catheter may be warranted. Aggressive intravenous fluids are usually effective in maintaining the blood pressure; however, at times, vasopressor agents, such as a norepinephrine infusion, may be required. Other therapies include oxygen, digitalis, and steroids.

Case Correlation

  • See Case 42 (Spontaneous Abortion). Rarely, patients with spontaneous abortion with retained products of conception can develop a septic abortion.