Septic Miscarriage

Septic miscarriage is infection of the products of conception and uterus during or after miscarriage or abortion, usually polymicrobial with Escherichia coli, Streptococcus, Staphylococcus and anaerobes. It follows unsafe abortion or retained tissue. It is a major cause of maternal death and needs immediate antibiotics and evacuation of the uterus.

• Common after unsafe or incomplete abortion.
• Risk factors: instrumentation, retained tissue, delay in care, HIV.
• May progress rapidly to sepsis and septic shock.

Patients present with fever, offensive vaginal discharge, lower abdominal pain, and bleeding after miscarriage or abortion. Examination shows tachycardia, tender uterus, and cervical motion tenderness.

• Temperature above 38 degrees Celsius or below 36 degrees Celsius.
• Heart rate above 100 per minute, respiratory rate above 22 per minute.
• Peritonism suggests uterine perforation or bowel injury.
• Differential diagnosis: pelvic inflammatory disease, appendicitis, urinary tract infection, malaria, pyelonephritis, retained products without sepsis.
• Complications: septic shock, disseminated intravascular coagulation, pelvic abscess, peritonitis, acute kidney injury, infertility, death.

The diagnosis is clinical, supported by tests to establish severity and source.

• Full blood count, blood culture before antibiotics where possible, high vaginal swab, urea and creatinine, lactate, blood group, malaria test.
• Ultrasound for retained tissue, pelvic collection or free fluid; erect abdominal X-ray for free air if perforation is suspected.
• Monitor urine output, target above 0.5 mL/kg/hour.
• A systolic blood pressure below 90 mmHg or lactate above 2 mmol/L indicates severe sepsis.

The principle is early broad-spectrum antibiotics, resuscitation and evacuation of the uterus within hours.

• Supportive: oxygen to maintain saturation above 94 percent; two large-bore cannulae; Ringer's lactate 30 mL/kg IV over the first 3 hours; noradrenaline if blood pressure stays low after fluids; urinary catheter for hourly output; high dependency care.
• Pharmacological: ampicillin 2 g IV 6-hourly plus gentamicin 5 mg/kg IV once daily plus metronidazole 500 mg IV 8-hourly, started within the first hour; continue until afebrile for 48 hours, then amoxicillin-clavulanate 625 mg oral 8-hourly to complete 7 days; tetanus toxoid 0.5 mL IM if the abortion was unsafe; paracetamol 1 g oral or IV 6-hourly.
• Procedures: manual vacuum aspiration or gentle evacuation after the first dose of antibiotics, within 6 hours of presentation; laparotomy for perforation, bowel injury or abscess; hysterectomy for clostridial infection or uncontrolled sepsis.
• Special groups: renal impairment, replace gentamicin with ceftriaxone 2 g IV daily; anaphylactic penicillin allergy, use clindamycin 900 mg IV 8-hourly plus gentamicin; Rhesus negative women give anti-D immunoglobulin 250 IU IM within 72 hours.
• Red flags: systolic blood pressure below 90 mmHg, altered consciousness, oliguria, bleeding from other sites, rigid abdomen.
• Follow-up: review at 1 week and 6 weeks; check haemoglobin and treat anaemia; counsel on contraception and future fertility; offer HIV testing.