Table 2.

Steps in Clinical Management of Septic Abortion (Based on [10, 20, 25–32])

• Confirm pregnancy and document gestational age.

• Document any previous or attempted uterine instrumentation, length and time of vaginal bleeding, history suspicious for rupture of membranes, length of fever, and any other symptoms.

• Features suggestive of possible sepsis include fever and/or chills, diarrhea and/or vomiting (possible toxic shock), rash (associated with Streptococcus infection), abdominal/pelvic pain/tenderness, foul-smelling vaginal discharge, productive cough, urinary tract symptoms.

• Evaluate uterine cavity by ultrasound for retained products of conception.

• Vital signs: temperature, pulse, blood pressure, respiration, oxygen saturation.

• Physical examination, to include:

o Vaginal speculum examination to look for trauma to the vaginal/cervix/uterus, foul-smelling discharge, presence of foreign bodies;

o Exploration of the cervix/uterus with ring forceps to look for retained products of conception;

o Cervical and uterine cultures, both aerobic and anaerobic, including assessment of sexually transmitted infections such as gonorrhea, chlamydia, and trichomoniasis;

o Bimanual pelvic examination (including digital rectal examination), with special attention to the presence of cervical motion or uterine tenderness, presence of adnexal masses;

o Abdominal examination for direct and rebound tenderness.

• Blood and urine cultures. The most common serious infection in pregnant patients is acute pyelonephritis, which may present similarly to septic abortion and which can also progress rapidly to urosepsis, acute respiratory distress syndrome, and septic shock.

• Laboratory studies, to include complete blood count, serum lactate, coagulation studies, renal function tests, blood type, and screen for possible transfusion (Rh-factor is especially important in pregnancy).

• Radiographic studies including abdominal flat plate and/or CT scan to look for free air in the abdomen, which may indicate organ perforation or gas in the myometrium, suggesting the presence of clostridial infection.

• Intravenous fluids and initial broad-spectrum antibiotics (typically ampicillin and gentamicin with clindamycin or metronidazole). Antibiotics should be administered promptly, intravenously, and in advance of uterine evacuation.

o Antibiotics can be changed later depending on clinical responsiveness and the results of culture and sensitivity testing, but it is essential to provide prompt initial broad-spectrum antibiotic coverage as soon as sepsis is suspected.

• Uterine curettage to remove retained products of conception. Suction curettage with anesthesia is usually preferred, but manual vacuum aspiration may be done on the ward if the patient is clinically stable. This is especially useful in low-resource settings. Due to the risk of bacteremia during curettage, broad-spectrum intravenous antibiotics must be on board before the procedure. Sharp curettage may heighten the risk of bacteremia and should be avoided if possible.

• Pathological examination of curettings with culture of any products of conception.

• Advanced intensive medical treatment in the presence of septic shock, including vasopressors, central venous monitoring, and ventilator support as clinically indicated. Patients with septic abortions may develop multisystem organ failure including acute respiratory distress syndrome, disseminated intravascular coagulopathy, acute renal failure, and septic cardiomyopathy that require aggressive management in a well-equipped intensive care unit.

Abbreviation: CT, computed tomography.