Postabortal Endometritis

Postabortal endometritis is infection of the uterine lining after spontaneous, induced or unsafe abortion. It is a common cause of septic abortion and abortion-related death.

• It results from retained products of conception, instrumentation, or ascending infection.
• Organisms include streptococci, Escherichia coli, anaerobes, Staphylococcus aureus, Clostridium species and chlamydia or gonorrhoea.
• Early antibiotics and evacuation of the uterus are life-saving.

Fever, lower abdominal pain, foul-smelling vaginal discharge, vaginal bleeding after abortion, uterine tenderness and open cervical os with products.

• Tachycardia, hypotension, rigors, peritonism with perforation, and jaundice or oliguria in severe cases.
• Differential diagnosis: retained products of conception, pelvic inflammatory disease, uterine perforation, ectopic pregnancy, appendicitis, urinary tract infection, malaria.
• Complications: sepsis, septic shock, pelvic abscess, peritonitis, uterine or bowel perforation, disseminated intravascular coagulation, renal failure, Asherman syndrome and infertility.

Diagnosis is clinical, with cultures and imaging to find retained tissue, abscess or perforation.

• Clinical diagnosis with history of abortion or instrumentation.
• Full blood count, C-reactive protein, blood cultures, high vaginal and endocervical swabs, urine culture.
• Urea and creatinine; lactate; clotting screen; blood group and Rhesus status.
• Pelvic and abdominal ultrasound; erect abdominal X-ray for free gas with perforation.
• Malaria test; HIV and syphilis tests.

Start antibiotics at once, evacuate the uterus, and resuscitate.

• Supportive: resuscitation with IV crystalloid 30 mL/kg for hypotension, oxygen, blood transfusion for anaemia, urinary catheter with output monitoring, tetanus toxoid 0.5 mL IM.
• Pharmacological: start antibiotics immediately: ampicillin 2 g IV 6-hourly plus gentamicin 5 mg/kg IV once daily (maximum 480 mg) plus metronidazole 500 mg IV 8-hourly, until afebrile for 24 to 48 hours. Alternative: ceftriaxone 1 g IV daily plus metronidazole 500 mg IV 8-hourly plus doxycycline 100 mg oral 12-hourly for 14 days. Suspected Clostridium or gas gangrene: add clindamycin 900 mg IV 8-hourly. Septic shock: noradrenaline infusion if blood pressure stays low. Rhesus-negative women: anti-D immunoglobulin 250 IU IM up to 20 weeks, 500 IU after 20 weeks, within 72 hours. Paracetamol 1 g oral or IV 6-hourly (maximum 4 g in 24 hours).
• Procedures: evacuate the uterus by manual vacuum aspiration within 6 hours of the first antibiotic dose; laparotomy for perforation, bowel injury or abscess; hysterectomy for uncontrolled sepsis, gas gangrene or severe uterine necrosis.
• Special groups: in renal impairment adjust gentamicin or use ceftriaxone plus metronidazole; in HIV infection check CD4 and start antiretroviral treatment; in unsafe abortion offer counselling and contraception before discharge.
• Red flags: hypotension, oliguria, jaundice, peritonitis, bleeding disorder, respiratory distress, crepitus.
• Follow-up: review at 1 week; contraception counselling and offer at discharge (implant, injectable or intrauterine device after infection resolves); review at 6 weeks.