Septic Abortion

Septic abortion is uterine infection associated with spontaneous or induced abortion (before 24 weeks), usually following incomplete evacuation, retained products of conception, or unsafe, unsterile instrumentation, and it may progress to pelvic infection, bacteraemia, septic shock, disseminated intravascular coagulation, acute renal failure and death.

Unsafe abortion accounts for about 8 to 13% of maternal deaths globally, mostly in low income countries where legal restrictions limit access. Organisms are polymicrobial: E. coli, Klebsiella, Bacteroides, anaerobic streptococci, group A streptococcus, Clostridium perfringens (gas gangrene, haemolysis with severe toxicity), Staphylococcus aureus, Enterococcus, and Chlamydia trachomatis and Neisseria gonorrhoeae.

Risk factors: unsafe abortion practices, retained tissue, intrauterine contraceptive device in situ, pre-existing cervicovaginal infection, and delayed care.

• Fever, chills, lower abdominal pain, foul smelling vaginal discharge, heavy or prolonged vaginal bleeding after abortion
• Tender, boggy uterus, cervical motion tenderness, open cervical os with products
• Signs of peritonitis (perforation of the uterus or bowel from instruments), pelvic abscess
• Sepsis: tachycardia, hypotension, tachypnoea, oliguria, confusion, jaundice, haemolysis (Clostridium), purpura (DIC), and respiratory distress (ARDS)
• Foreign body or instrument trauma history

• Clinical diagnosis with history of abortion or instrumentation
• Blood tests: full blood count, C-reactive protein, urea, creatinine, electrolytes, liver function, lactate, coagulation, group and crossmatch, pregnancy test
• Cultures: blood, high vaginal and endocervical swabs, products of conception, urine; chlamydia and gonorrhoea PCR
• Imaging: pelvic ultrasound (retained products, free fluid, collections), erect chest and abdominal radiograph (free air from perforation, foreign body, gas in uterus), CT abdomen and pelvis for abscess, perforation, or necrotising infection
• Test for HIV, hepatitis B, syphilis

• Resuscitate: oxygen, IV fluids (30 mL/kg crystalloid if hypotensive), urinary catheter, correction of coagulopathy, and early critical care review.
• Start broad spectrum antibiotics immediately. One option is ceftriaxone 2 g IV daily plus metronidazole 500 mg IV every 8 hours plus doxycycline 100 mg every 12 hours (or azithromycin 500 mg daily).
• Another option is piperacillin tazobactam 4.5 g IV every 6 hours.
• The traditional regimen is clindamycin 900 mg IV every 8 hours with gentamicin 5 mg/kg daily, plus ampicillin 2 g every 6 hours.
• Add meropenem for severe sepsis or resistant organisms, and clindamycin for toxin mediated disease (Clostridium, GAS).
• Evacuate the uterus promptly, after the first dose of antibiotics and ideally within 1 to 6 hours. Use suction curettage under anaesthesia with careful technique (high risk of perforation), or oxytocin assisted evacuation. Misoprostol is not preferred in septic cases.
• Laparotomy or laparoscopy for uterine perforation, bowel injury, peritonitis, necrotising myometritis, pelvic abscess, or poor response at 48 to 72 hours. Hysterectomy for refractory sepsis, Clostridium infection, or uterine necrosis.
• Tetanus prophylaxis (tetanus toxoid 0.5 mL IM, and tetanus immunoglobulin 250 IU for unsafe abortion).
• Anti-D immunoglobulin 250 to 500 IU (50 to 100 micrograms) IM for Rh negative women within 72 hours.
• Post-abortion: continue antibiotics until afebrile for 24 to 48 hours (full course 7 to 14 days); contraception counselling and psychosocial support; screen and treat for STIs.
• Complications: AKI, ARDS, DIC, Asherman syndrome, pelvic inflammatory disease, infertility, ectopic pregnancy risk.