Septic Abortion: Prevention and Management
Phillip G. Stubblefield and David A. Grimes
Table Of Contents
Phillip G. Stubbblefield, MD
David A. Grimes, MD
SCOPE OF THE PROBLEM|
PRIMARY PREVENTION OF SEPTIC ABORTION
SECONDARY PREVENTION OF SEPTIC ABORTION
TERTIARY PREVENTION OF SEPTIC ABORTION
Septic abortion, an infected abortion complicated by fever, endometritis, and parametritis,1 remains one of the most serious threats to women’s health worldwide. Although morbidity and mortality from septic abortion are infrequent in countries in which induced abortion is legal, suffering and death from this process are widespread in many developing countries in which abortion is either illegal or inaccessible. Septic abortion is a paradigm of preventive medicine, relating all levels of prevention—primary, secondary, and tertiary.2 In previous years, obstetricians/gynecologists were often the experts in management of sepsis. However, those who have trained since the legalization of abortion may have little experience with septic abortion, so management is reviewed in some detail.
|SCOPE OF THE PROBLEM|
A 1973 report from a prestigious medical journal described an adolescent admitted to a major Boston teaching hospital with what proved to be incomplete septic abortion. Uterine evacuation was not performed until several days after admission because this diagnosis was not initially entertained. The patient died despite massive antibiotic therapy and intensive medical management.3 Tragedies of this sort are now rare.
The most important public health effect of the legalization of abortion4 was the near elimination of deaths from illegal abortion in the United States. Illegal abortion deaths are disproportionately due to infection.4,5 In a 1994 U.S. review, 62% of illegal abortion deaths and 51% of spontaneous abortion deaths were from infection, whereas only 21% of legal abortion deaths were from infection.6 Risk of death from postabortion sepsis is greatest for younger women and unmarried women, and it is more likely with procedures that do not directly evacuate the uterine content.7 With more advanced gestations, the risk of perforation and retained tissue increases.7 Delay in treatment allows progress to bacteremia, pelvic abscess, septic pelvic thrombophlebitis, disseminated intravascular coagulopathy, septic shock, renal failure, and death.8
U.S. maternal deaths from all causes have declined rapidly since 1940.9 Nonabortion maternal mortality declined steadily. Abortion mortality exhibited three phases: an initial decline until 1950, a plateau from 1951 to 1965, and then a very rapid decline from 1965 to 1976 (more rapid than that of maternal mortality from other causes) as legal abortion became increasingly available (Fig. 1). In 1992, the last year for which complete data are available, 10 deaths were reported of 1,359,145 legal induced abortions, for a case-fatality rate of 0.7 per 100,000 legal abortions.6 By comparison, in the 1940s, over 1000 women per year were known to have died from abortion in the United States.5 The American Medical Association’s Council on Scientific Affairs has attributed the marked decline in abortion deaths in this century to the introduction of antibiotics to treat sepsis, the widespread use of effective contraception beginning in the 1960s, which reduced the numbers of unwanted pregnancies, and more recently, the shift from illegal to legal abortion.10
Serious complications have become rare as well. A large series from Planned Parenthood of New York City describes 170,000 abortions performed in outpatient settings by a small group of expert practitioners.11 No deaths occurred, and only 121 hospitalizations for complications occurred, 0.71 per 1000 abortions. Approximately 3.5 million unwanted pregnancies occur each year in our country,12 and with the continuing attack on legal abortion services13 and current barriers to access,14 the demand for abortion may lead to a resurgence in illegal abortion.
Western Europe and the Former Soviet Union
The experience in Western Europe has been very similar to that in the United States, with legal abortion becoming widely available and very low rates of abortion mortality currently reported.15 Overall, maternal mortality from legal abortion in Europe is less than 1 per 100,000 procedures. Death rates are somewhat higher in the former Soviet Union, where the special problem of illegal abortion with a markedly higher risk of death has emerged.16
The Third World
Abortion remains a major cause of maternal death in Third World countries. The World Health Organization (WHO) estimates that 80,000 deaths from unsafe abortion occur in the world every year, about 13% of all maternal deaths.17 Most of these maternal deaths occur in underdeveloped countries. A WHO working paper summarizing the world literature after 1960 lists almost 400 published reports of abortion morbidity and mortality and concludes that “unsafe abortion is one of the greatest neglected problems of health care in developing countries.”18 The proportion of maternal deaths that result from unsafe abortion is probably considerably larger. Where abortion is illegal, women and health care professionals are reluctant to report that abortion was induced.19 Private personal dialogue with women by trained, empathetic caseworkers reveals a higher proportion of induced abortions.20
The preventable morbidity and mortality from septic abortion are staggering and well documented.21 A 1992 report of Guinea, in West Africa, reported an investigation of all maternal deaths in the capital from July 1, 1989, to June 30, 1990.22 The most common causes were hypertensive diseases (20%), postpartum bleeding (19%), and abortion (17%). Eighty percent of the abortion deaths were known to be from induced abortion. Sepsis was the most common cause of death. A study from five hospitals in Kampala, Uganda, in East Africa, for the period 1980 to 1986 found 20% of maternal deaths to be abortion-related.23 A Nigerian study reported that 35% of hospital maternal mortality was from abortion, with sepsis the most common cause of death.24 A 7-year review of abortion at the University College Hospital in Ibadan, Nigeria, reported that abortion complications represented 76.7% of all emergency gynecologic admissions.25 A population-based survey in rural Bangladesh identified 387 maternal deaths from 1976 to 1985 (555 per 100,000 live births).26 Principal causes of death were postpartum hemorrhage (20%), abortion (18%), and toxemia/eclampsia (12%).
In 1990, 36 hospitals and medical schools from four Latin American countries participated in a multinational study of all women attended for abortion during a 6-month period.27 During this time, 14,501 abortion admissions were recorded and 8871 were investigated. At the same time 113,714 births occurred in the participating hospitals. Fifteen percent of the abortions were classified as septic on admission. Forty-three women of the 8871 required hysterectomy, and 36 women died, producing an abortion maternal mortality rate of 406 per 100,000 women admitted for abortion. Although hemorrhage was the most common abortion complication, 75% of the deaths were in women admitted as “septic.” The problem may actually be escalating in some areas. A 10-year review from Rio de Janeiro found maternal mortality to have increased almost fourfold from 1978 to 1987 (128 per 100,000 to 462 per 100,000). Abortion-related deaths accounted for 47% of the total mortality.28 As shown in all of these studies, abortion deaths are primarily from sepsis.
More recent reports from many countries echo the same dismal findings. A report of a 10-year study from rural India, published in 2001, found that 41.9% of all maternal deaths were from septic abortion, and the total maternal mortality rate was extraordinary (785 per 100,000 live births), approximately 100-fold greater than maternal mortality in developed countries.29
|PRIMARY PREVENTION OF SEPTIC ABORTION|
Primary prevention avoids the occurrence of disease or injury.2 Primary prevention of septic abortion includes access to effective and acceptable contraception; access to safe, legal abortion in case of contraceptive failure; and appropriate medical management of abortion.
Avoiding Unintended Pregnancy
Pregnancy places women at risk for illness and death. This risk may be gladly assumed with a desired pregnancy. Unwanted pregnancy places a woman at additional risk if she seeks abortion and safe services are not available.30,31 Reducing unwanted pregnancies is a goal to which both sides in the abortion controversy can agree, although the means to that end diverge.
A prerequisite to preventing unwanted pregnancy—in all nations—is social equality: the elevation of women’s status so that they can avoid coercive sexual relationships and use contraceptive methods that they regard as safe and free of side effects.31 In the United States, age-specific abortion ratios make it clear that women at greatest risk for unwanted pregnancy are adolescents and young adults.32 Marriage and intentional childbearing are delayed, but sexual activity is not. National surveys consistently show 11% to 12% of reproductive-age women to be sexually active with no contraception.33 Publicly funded contraceptive services do not serve all who need them. No increase in the funding for public family planning services has been seen in more than a decade. Sexuality education often fails to inform about contraception because of a misguided notion that such education about contraception encourages sexual experimentation. In fact, adolescents coming to family planning clinics are typically sexually active long before seeking services.34 Education about biology is not enough. Actual services must be provided that are readily accessible and inexpensive.
Confirm diagnosis of pregnancy with urine pregnancy test
HIV, human immunodeficiency virus.
* Gynetech, Lebanon, NJ
† Cabot Laboratories, Langhorne, PA
Data from Hern WM: Abortion Practice. Philadelphia, JB Lippincott, 1984; and Stubblefield PG: Pregnancy termination. In Gabbe SG, Niebyl JR, Simpson JL (eds): Obstetrics: Normal and Problem Pregnancies, pp 1303–1332. 2nd ed. New York, Churchill Livingstone, 1991
Access to Safe Abortion Services
The need for safe, legal abortion is nowhere more clearly shown than in the Romanian experience. When abortion was outlawed in the 1960s, the abortion-related maternal mortality rate rose 10-fold. An estimated 10,000 women died from this policy over the 23 years of its imposition.35 The death rate fell only when abortion was again legalized. The public health message of this bizarre natural experiment is clear: when abortion is legal and accessible, women’s health improves, and vice versa. No evidence supports the claim that restricting abortion reduces the number performed. Abortion rates and ratios are as high or higher in countries in which abortion is completely illegal as in countries in which it is legal and readily available.36
Components of Safe Abortion Services
The risk from abortion rises with gestational age, increasing in the second trimester.6 Therefore, safe services are needed early in pregnancy. Access is especially a problem for disadvantaged women, including the young, who in many jurisdictions must seek consent from their parents for abortion, but who may continue a pregnancy, a far more dangerous course, on their own.37
The technology for first trimester abortion is not complicated (Table 1). In the first trimester and early midtrimester, abortion is readily performed by vacuum curettage in an outpatient or office setting.38,39 Prophylactic antibiotics reduce the risk of febrile morbidity after abortion.40
|SECONDARY PREVENTION OF SEPTIC ABORTION|
Secondary prevention requires early detection and treatment, with the goal of halting the disease process.2 Secondary prevention of septic abortion entails prompt diagnosis and effective treatment of endometritis to avoid more serious infections. The diagnosis of septic abortion must be suspected when any reproductive-age woman presents with vaginal bleeding, lower abdominal pain, and fever. A common theme in reported deaths from septic abortion is delay: young or unmarried women often conceal the abortion and delay seeking help until moribund. In this setting, a sensitive pregnancy test (capable of detecting 20 to 50 mIU/mL of beta-human chorionic gonadotropin [beta-hCG]) will usually be positive, because it takes 4 to 6 weeks for beta-hCG to become undetectable after complete uterine evacuation.
A rapid initial assessment is needed to determine the severity of the problem. If the patient has been symptomatic for several days, more generalized, serious illness may be present. When possible, the abortion provider should be contacted to determine details of the procedure—whether complications were suspected at the time, the length of gestation and quantity of pregnancy tissue removed, results of any screening bacteriologic studies, and pathologic examination of aborted tissue. With more advanced gestations, there is greater risk of perforation and of retained tissue. Perforation markedly increases the risk of serious sepsis.7 Illegal abortion by insertion of rigid foreign objects increases risk for perforation.41 Intrauterine instillation of soaps poses a special hazard for uterine necrosis and renal failure.42
The abdominal and pelvic examinations merit special attention. The examiner should 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, radiographic studies of the abdomen may help identify free air or foreign bodies. Disseminated sepsis is suggested by high fever and prostration, tachycardia, tachypnea, respiratory difficulty, and low blood pressure.8,43 Some women develop a mild illness, presenting with a triad of symptoms: low-grade fever, mild lower abdominal pain, and moderate vaginal bleeding. Patients presenting with these symptoms usually have either incomplete or failed abortion (continuing pregnancy) or hematometra (retained clotted and liquid blood).44 Ideal management is immediate re-evacuation in the ambulatory clinic or the emergency room. This can be readily accomplished safely and humanely by vacuum curettage with local anesthesia and intravenous sedation. In a large U.S. series, 3.5 patients per 1000 had re-evacuation in the abortion clinic, which undoubtedly contributed to the authors’ remarkably low rate of hospitalization for septic abortion, 0.21 per 1000.11
The bacteriology of septic abortion is usually polymicrobial, derived from the normal flora of the vagina and endocervix, with the important addition of sexually transmitted pathogens.45 Gram-positive and gram-negative aerobes and facultative or obligate anaerobes, Neisseria gonorrhoeae, and Chlamydia trachomatis are all possible pathogens.8 In the United States, infection with Clostridium perfringens is largely associated with illegal abortions.8,43 In Third World countries, tetanus contributes to septic abortion death.21 Because of the variety of bacterial agents found in infected abortions, no one antibiotic agent is ideal. The Centers for Disease Control and Prevention’s recommended regimens for outpatient management of pelvic inflammatory disease are appropriate for patients with early postabortal infection limited to the uterine cavity. One such regimen is ofloxacin plus either clindamycin or metronidazole.46 Evaluation of the patient at 48 hours is essential, with hospitalization if fever and pain persist.
|TERTIARY PREVENTION OF SEPTIC ABORTION|
Tertiary prevention minimizes the harm done by disease and avoids disability.2 Tertiary prevention of septic abortion seeks to avoid serious consequences of infection, including hysterectomy and death. Patients with more established infection, as indicated by temperature elevation (arbitrarily defined as >38°C), pelvic peritonitis, or more severe disease should be hospitalized for parenteral antibiotic therapy and prompt uterine evacuation. Bacteremia is more common with septic abortion than with other pelvic infections: septic shock and adult respiratory distress syndrome (ARDS) may result.41 Management of severe sepsis requires eradication of the infection and supportive care for the cardiovascular system and other involved organ systems.8,47
Eradicating the Infection
Blood, urine, and cervical cultures are taken, and high-dose broad-spectrum antibiotics are begun intravenously. 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.
One time-honored regimen for severe pelvic sepsis is penicillin (5 million units intravenously [IV] every 6 hours) or ampicillin (2 to 3 g IV every 6 hours) combined with clindamycin (900 mg IV every 8 hours) and an aminoglycoside, either gentamicin or tobramycin (2 mg/kg loading dose, followed by 1.5 mg/kg every 8 hours depending on blood levels and renal status).
Emptying the Uterus
Remaining pregnancy tissue must be evacuated without delay as soon as antibiotic therapy and fluid resuscitation are begun. Hesitation of physicians to evacuate the uterus because of the poor condition of the patient is a common theme in fatal septic abortion in the United States.7 Vacuum curettage is readily accomplished with the patient under local anesthesia with minimal intravenous sedation, and if necessary, this can be performed in an intensive care unit bed.
A retained fetus from midtrimester abortion poses a special challenge. The uterus usually can be readily evacuated by a curettage procedure, facilitated by ultrasound guidance, if a practitioner experienced with midtrimester dilation and evacuation abortions is available. Otherwise, a medical means for uterine evacuation is needed. Although little information is available about its use in the context of septic abortion, misoprostol, a prostaglandin E1 analogue widely used for induction of abortion in the first and second trimesters is likely the drug of choice for this purpose. Misoprostol has fewer side effects than the older prostaglandins and is inexpensive, stable at room temperature, and widely available.48 Vaginal doses of 200 to 400 μg at 6 hourly intervals are highly effective for inducing abortion in the midtrimester.49
Alternatively, high-dose oxytocin can be used. Fifty units of oxytocin is given in 500 mL of 5% dextrose and normal saline solution over a 3-hour period (approximately 278 mU/min). This is followed by a 1-hour rest and repeated, adding 50 additional units to the next 500-mL infusion, and continuing 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).50
If none of these means is available, another option is a metreurynter: A Foley catheter with a 50-cm3 balloon is placed in the lower uterus and the balloon inflated to 50 to 75 cm3. One kilogram of traction from an orthopedic weight at the foot of the bed is then attached to the catheter. This dilates the cervix and stimulates contractions.
The Role of Laparotomy
Laparotomy will be needed if the patient does not respond to uterine evacuation and adequate medical therapy. Other indications are uterine perforation with suspected bowel injury, pelvic abscess, and clostridial myometritis.43 Although ultrasound-guided percutaneous needle aspiration of pelvic abscesses is practiced, the technique is still new, and in critically ill women with severe postabortal sepsis, hysterectomy will likely be needed in addition to drainage of any abscess. 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 are indications for total hysterectomy and possible removal of both uterine adnexae. Operative cultures should be obtained. 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.
Abdominal closure should be by interrupted internal stays (Smead-Jones or similar) or a running mass ligature including peritoneum, rectus muscles, and rectus fascia. The subcutaneum and skin are left open with sutures placed for a delayed primary closure, and the wound is packed.
Patients with severe sepsis and septic shock should be managed in intensive care settings in collaboration with physicians and nurses trained in critical care medicine. Cardiovascular support attempts to restore near-normal blood pressure and tissue perfusion.43,51,52 Principles of management of postabortal septic shock are not different from those of other causes, other than the need to ensure evacuation of the uterus. Cuff blood pressures are not reliable in septic shock. An arterial line is needed for blood pressure monitoring. A balloon flotation right-heart catheter should be placed for measurement of pulmonary artery wedge pressure (PAWP), cardiac output, and systemic vascular resistance. A central venous pressure catheter and additional peripheral venous lines are placed. Urinary output is monitored with an indwelling urinary catheter. Fluid resuscitation is given to achieve a target mean arterial pressure (MAP) of 60 mm Hg without exceeding a target PAWP of 12 to 15 mmHg to maximize left ventricular performance.51,52
Initial fluid resuscitation will require 200 mL per 10-minute interval. Fifteen to 20 L may be required in the first 24 hours. Anemia is corrected with packed red blood cells, to a hematocrit of 30% to 35%, and salt-poor albumin is given to reach a serum albumin of 2 g/100 mL. The balance of the fluid is crystalloid. Vasopressors are added if the PAWP reaches 15 before a target MAP of 60 is achieved. Dopamine and dobutamine are preferred. If dopamine is chosen, initial therapy is 1 to 3 mcg/kg/min and is increased gradually. At low doses, dopamine increases heart rate, myocardial contractility, and MAP while maintaining renal perfusion.51,52 At higher doses, vasoconstriction and alpha-adrenergic effects predominate. If target MAP is not reached at 20 mcg/kg/min, norepinephrine is used at 2 to 10 mcg/min. Dopamine is continued at 2 to 5 mcg/kg/min to enhance renal perfusion.
Management of Pulmonary Complications
ARDS will develop in 25% to 50% of patients with septic shock.45 Tissue oxygenation should be monitored with blood gases and pulse oximetry, and mechanical ventilation is begun early if O2 saturation falls below 90% or if pulmonary compliance begins to decrease.
High-dose corticosteroid therapy is no longer recommended, after two randomized trials failed to find benefit.53,54 A number of studies have found benefit from intravenous polyvalent immunoglobulin (IVIG) in sepsis. A Cochrane review of 27 qualifying randomized trials found that IVIG significantly reduced both overall mortality and sepsis-related mortality.55 The same review found no benefit for therapy with monoclonal antibodies to specific endotoxins and cytokines. Recombinant human activated protein C (drotrecogin alpha [Xigris], Lilly, Inc., Indianapolis, IN) has been shown to reduce the mortality risk from sepsis with acute organ dysfunction.56 In a very large randomized trial, the death rate in the placebo-treated group was 30.8%, whereas among the drotrecogin alpha–treated patients, 24.7% died, a 19.4% reduction (p = .005). Hyperbaric oxygenation may improve the outcome with clostridial myonecrosis when used in combination with effective surgical and antibiotic therapy.57
Death and serious complications from abortion-related infection are almost entirely avoidable. Unfortunately, prevention of death from abortion remains more a political than a medical problem. Although leaders in international health have repeatedly drawn attention to abortion complications and maternal mortality, many governments and health care agencies still lack the moral courage to confront the problem.58 For health professionals, the ethical issues have been clearly defined: We have a duty “to affirm our own commitment to health values. We are obligated to put health first, to do so by respecting the best available scientific evidence, and to be frank when we put aside such evidence for other considerations, be they moral, or religious, or economic, or simply expedient.”59
15. Henshaw SK: How safe is therapeutic abortion? In Teoh ES, Ratnam SS, Macnaughton M (eds): Pregnancy Termination and Labor. pp 31, 41 Lancaster, UK, Pearl River, NY, Parthenon Publishing Group, 1993
17. World Health Organization/Division of Reproductive Health: Unsafe abortion: Globaland regional estimates of incidence and mortality due to unsafe abortion, with a listing of available country data. (WHO/RHT/MSM/97.16). Geneva, WHO, 1998
18. World Health Organization, Maternal and Child Health Unit and Family Planning, Division of Family Health: Abortion: A Tabulation of Available Data on the Frequency and Mortality of Unsafe Abortion. 2nd ed.. Geneva, WHO, 1993
27. Pardo F, Uriza G: y el Federacion Colombiano de Sociedades de Obstetricia y Ginecologia: Estudio de morbilidad y mortalidad por aborto en 36 institucions de Bolivia, Colombia, Peru, y Venezuela. Rev Colombiana Obstet Ginecol 42:287, 1991
49. Dickinson JE, Evans SF: The optimization of intravaginal misoprostol dosing schedules in second trimester pregnancy termination. Am J Obstet Gynecol 186:470, 2002
50. Winkler CL, Gray SE, Hauth JC, et al: Mid second trimester labor induction: Concentrated oxytocin compared with prostaglandin E2 vaginal suppositories. Obstet Gynecol 77:297, 1991
53. Bone RC, Fisher CJ, Clemmer TP, et al and the Methylprednisolone Sepsis Study GroupA controlled clinical trial of high-dose methylprednisolone in the treatment of severe sepsis and septic shock. N Engl J Med 317:653, 1987