This document discusses septic abortion, which occurs when an abortion becomes infected. It defines septic abortion and outlines its epidemiology, causes, clinical presentation, investigations, complications and management approach. Septic abortion is most commonly associated with unsafe or illegal induced abortions where proper aseptic techniques are not followed. Management involves controlling infection through antibiotics, removing the infection source by evacuating the uterus, and providing supportive care. More severe cases involving sepsis or organ dysfunction may require intensive care. Prevention focuses on increasing contraceptive access and promoting safe abortion services.

1. Septic abortion
Revision for members
Dr. Lawrence Buadi
GARH

2. Introduction
• Abortion: the spontaneous or induced termination of pregnancy
before fetal viability
• WHO: Expulsion or extraction from its mother of an embryo or fetus
weighing 500g or less when it is not capable of independent survival

3. Introduction
• GMHS 2017-27% used Non-medical methods for abortion
• Abortion public health concern in low- and middle-income countries
• Abortion one of the main contributors to MMR in Ghana
• High fertility rate, low contraceptive usage and obstacles to safe
abortion care contributes significantly to unsafe abortion and
therefore bad outcomes

4. Types of Abortion
Spontaneous
• Complete
• Incomplete
• Missed
• Threatened
• Inevitable
• Septic- less common
Induced
• Legal
• Illegal(unsafe)
• Septic-common

5. Types of spontaneous abortion
• Inevitable: intrauterine gestation with cervical dilatation and vaginal
bleeding
• Incomplete: cervix opened and some poc passed
• Complete: pregnancy has been expelled completely
• Missed: embryo never formed/demise, but uterus has not expelled
sac
• Septic: missed/incomplete becomes infected

6. Septic abortion
• Any abortion associated with clinical evidences of infection of the
uterus and its contents is called septic abortion
• Abortion usually considered septic if:
• Rise of temperature of at least 38°C for 24 hours or more
• Offensive or purulent vaginal discharge
• Other evidences of pelvic infection such as lower abdominal pain and
tenderness

7. Epidemiology of septic abortion
• 10% of abortions requiring admission to hospital are septic
• Most of them are associated with incomplete abortion
• Majority of cases the infection occur following illegally
induced/unsafe abortion
• Can also occur following spontaneous abortion

8. Association of sepsis in illegally induced
abortion
• Proper antiseptic and asepsis are not adhered to
• Incomplete evacuation
• Inadvertent injury to the genital organs and adjacent structures,
particularly the bowels

9. Mode of infection(organism involved (normal
flora)
• Anaerobes
• Clostridium welchii
• Anaerobic Streptococci
• Tetanus bacillus
• Bacteroides group (fragilis)
• Aerobes
• Escherichia coli ,
• Klebsiella Staphylococcus,
• methicillin resistant
staphylococcus aureus (MRSA)
• Pseudomonas
• Group A beta Hemolytic
Streptococcus

10. Pathophysiology
• Sepsis begins from vaginal bacteria invasion of uterus
• Bacteria gains access into maternal intervillous space of placenta
• Bacteremia occurs in the intervillous space in >60% cases of septic
abortion
• Presence of toxins by some bacteria plus overwhelming immune
response to infection systemic dx and multi-organ failure
• Prolonged presence of infected POC invasion of decidua of the
endometrium myometrium and outside of uterus

11. Pathology
• In 80% of the cases; organisms are endogenous in origin
• Infection is localized to the conceptus
• No myometrial involvement
• In 15 % cases
• Infection produce localised endomyometritis
• In 5 % cases
• Generalized peritonitis and/or endotoxic shock
• Severe necrotizing infections and toxic shock syndrome caused by group A
streptococcus - S. pyogenes

12. Clinical Grading
• Grade–I:
• The infection is localized to the uterus
• Grade–II:
• The infection spreads beyond the uterus to the parametrium, tubes and
ovaries or pelvic peritoneum
• Grade–III:
• Generalized peritonitis and/or endotoxic shock or jaundice or acute renal
failure
• Almost always associated with illegal induced

13. Clinical features
Depends on severity and extent of infection
• Sick & anxious
• Temperature > 38°C
• Chills and Rigor (S/0 Bacteremia)
• Hypothermia < 36°C (Endotoxic shock)
• Persistent tachycardia ≥ 90 bpm
• Tachypnea >20/min

14. Clinical features
• Impaired mental status
• Abdominal or chest pain
• Diarrhea & vomiting
• Renal angle tenderness
• Pelvic examination
• Offensive purulent vaginal discharge
• Uterine tenderness
• Boggy feel in Pouch of Douglas (Pelvic Abscess)

15. Investigation
Routine investigations:
• Cervical or high vaginal swab for
• culture in aerobic and anaerobic media
• sensitivity of the microorganisms to antibiotics
• Smear for Gram stain
• Blood- FBC, ABO & Rh
• Urine analysis and culture

16. Special investigations
• Pelvic/Abdominal Usg scan:
• Intrauterine RPOC
• Pyometria
• Foreign body (intrauterine or intra-abdominal)
• Free fluid in peritoneal cavity or pouch of Douglas
• Blood:
• Culture: if associated with chills & rigors
• Serum electrolyte, C- reactive proteins, serum lactate
• Coagulation profile
• Plain X ray:
• Abdomen: suspected of bowel injury
• Chest: Pulmonary complications (Atelectasis)

17. Complications
• Immediate:
• Hemorrhage- abortion process or injury inflicted during the interference
• Injury to the uterus and also to the adjacent structures particularly gut
• Spread of infection leads to:
• Generalized peritonitis
• the uterine tubes
• perforation of the uterus
• bursting of the micro abscess in the uterine wall
• Injury to the gut

18. Complications
• Endotoxic shock—mostly due to E. coli or Cl. Welchii infection
• Acute renal failure—patchy cortical necrosis or acute tubular necrosis
Cl. Welchii
• Thrombophlebitis

19. Complications
• The remote complications include
• Chronic debility
• Chronic pelvic pain and backache
• Dyspareunia
• Ectopic pregnancy
• Secondary infertility due to tubal blockage and
• Emotional depression

20. Prevention
• To boost up family planning acceptance to prevent unwanted
pregnancy
• To take antiseptic and aseptic precautions (internal examination or
operation)
• Encourage abortion in legal/safe situations – CAC
• Appropriate referral systems (conscientious objection)

21. Management
• General Management
• Grading Management

22. Management
• General management
• Hospitalization
• Vaginal/Cervical swab
• Vaginal Examination
• Overall assessment
• Investigation protocols

23. Principle of management
• To control sepsis
• To remove the source of infection
• To give supportive therapy - (In order to bring back to normal
homeostatic & cellular metabolism)
• To assess the response of treatment

24. Grading management
Grade I:
• Drugs:
• Antibiotics
• Prophylactic Antigas gangrene serum
• 8000 units and 3000 units of Antitetanus serum IM
• Analgesics & Sedatives
• Blood transfusion
• Evacuation of uterus: Excessive bleeding is an indication

25. Grading management
• Antimicrobial Therapy:
• Piperacillin-Tazobactam or Carbapenem+Clindamycin (IV)- broadest
range of microbial coverage
• Piperacillin-tazobactam & carbapenems
• Vancomycin or teicoplanin
• Clindamycin
• Gentamycin (3-5 mg/kg– single dose)
• Co- amoxiclav
• Metronidazole

26. Grading management
• Grade II:
• Drugs:
• Antibiotics
• Prophylactic Antigas gangrene serum
• Analgesics & Sedatives
• Blood transfusion more needed than in Grade I
• Clinical monitoring:
• Vitals
• Urinary output
• Progress of pain, tenderness
• mass in lower abdomen
• CVP greater than 8mmHg

27. Grading management
• Grade II:
• a) Evacuation of the uterus:
• Evacuation withheld for at least 48 hrs
• When infection is controlled and localized
• But excessive bleeding is an indication
• b) Posterior colpotomy:
• If infection localized in POD, pelvic abscess formed
• Causes Spiky rise in temperature
• Rectal tenesmus
• Boggy mass felt through post. fornix

28. Grading management
• Grade III:
• Antibiotics as in Grade I & II
• Clinical monitoring as in Grade II
• Supportive therapy:
• Treat generalized peritonitis
• By gastric suction
• Intravenous crystalloids infusion

29. Grading management
• Management of Endotoxic shock/ Renal Failure
• Features of Organ Dysfunction carefully guarded
• May need Intensive Care Unit Management
• Active Surgery

30. Features of Organ Dysfunction
• Persistent hypotension (SBP < 90 mm Hg)
• PaO2 : 44.2 umol/L
• Coagulation abnormalities (INR > 1.5)
• Thrombocytopenia
• Hyperbilirubinemia

31. Indication for ICU Management
CVS Persistent hypotension
Persistent elevated serum lactate
RESPIRATORY Pulmonary edema
Mechanical ventilation
Airway protection
RENAL Dialysis
NEUROLOGICAL Impaired consciousness
MISCELANEOUS Multi organ failure
Acidosis
Hypothermia

32. Active surgery
• Indications:
• Injury to uterus
• Suspected injury to bowel
• Presence of foreign body in pelvis/abdomen:
• Sonography/ Xray / felt through fornix on PV
• Unresponsive peritonitis as a result of pus collection
• Septic shock/Oliguria not responding to conservative treatment.
• Uterus too big to safely evacuate per vaginum

33. References
• Williams Textbook of Obstetrics, 24th edition
• DC Dutta’s Textbook of Obstetrics, 8th edition
• Anish Dhakal (Aryan) PPT
• Treating Spontaneous and Induced Septic Abortions (David A.
Eschenbach, MD), Clinical Expert Series.
• Septic abortion: a review of social and demographic characteristics,
(Henry Osazuwu et,al. 2006)
• Experiences of women seeking post abortion care services ina
regional hospital in Ghana (Kenneth Setorwu Adde et,al., 2021)