Version May 2024
INTRODUCTION — Septic abortion refers to any abortion, spontaneous or induced, that is complicated by severe uterine infection, including endometritis and parametritis. Septic abortion typically refers to pregnancies of less than 20 weeks gestation while those ≥20 weeks gestation with intrauterine infection are described as having intraamniotic infection.
This topic will discuss the clinical presentation, evaluation, and management of patients with septic abortion. Management of related uterine infections, including intraamniotic infection, postpartum endometritis, and pelvic inflammatory disease (PID), are discussed elsewhere.
●(See "Clinical chorioamnionitis".)
●(See "Postpartum endometritis".)
●(See "Pelvic inflammatory disease: Treatment in adults and adolescents".)
In this topic, when discussing study results, we will use the term "patient(s)" as used in the studies presented. We encourage the reader to consider the specific counseling and treatment needs of transmasculine and gender expansive individuals.
EPIDEMIOLOGY AND MICROBIOLOGY
●Incidence – The incidence of septic abortion is not fully known as it encompasses infection following both spontaneous pregnancy loss and pregnancy termination (medication and surgical). The data are further confounded by varying definitions of infection across studies and contemporary use of preoperative antibiotics prior to uterine aspiration procedures. (See "First-trimester pregnancy termination: Uterine aspiration", section on 'Antibiotic prophylaxis'.)
With those limitations, available data suggest a slightly higher incidence of infection with medication abortion compared with uterine aspiration.
•Uterine aspiration – In a systematic review of office-based first-trimester termination with uterine aspiration, infections requiring intravenous (IV) antibiotics occurred in 0 to 0.4 percent of patients [1].
•Medication abortion – A systematic review that included pregnancies up to 26 weeks gestation reported an infection rate of 0.92 percent following medication abortion [2].
•Unsafe abortion – Severe infection rates of 5 percent have been reported following unsafe abortion. (See "Unsafe abortion".)
●Microbiology – Vaginal bacteria that gain access to the uterine cavity can invade the placenta, endometrium, myometrium, and beyond. Routine vaginal flora, gastrointestinal flora, and anaerobic pathogens are typical [3-6]. In one study of 84 individuals with an infected abortion, the most commonly identified organisms were Enterobacteriaceae (35 percent), streptococci (31 percent), staphylococci (9 percent), and enterococci (9 percent) [7]. Group A Streptococcus as well as Clostridium and other anaerobic infections can develop and progress rapidly in postpartum individuals and those who have undergone medication abortion [8-11]. (See "Pregnancy-related group A streptococcal infection".)
CLINICAL FEATURES
Presenting scenarios — Septic abortion can occur after both induced and spontaneous abortion (ie, pregnancy loss or miscarriage).
●Pregnancy loss – Individuals in various states of pregnancy loss can develop intrauterine infection. These include those with a demised intrauterine pregnancy, a partially passed demised pregnancy (ie, incomplete abortion), or completed pregnancy loss with an infected uterus, often related to retained products of conception. Individuals with complications of early pregnancy loss may not know that they are, or recently have been, pregnant. (See "Pregnancy loss (miscarriage): Clinical presentations, diagnosis, and initial evaluation", section on 'Complicated (hemorrhage and/or infection)'.)
●Pregnancy termination – Intrauterine infection is a potential complication of both medication and surgical pregnancy termination. Infection can be associated with retained products of conception. To reduce the risk of infection, individuals undergoing surgical abortion with uterine aspiration receive a dose of preoperative antibiotics; infection rates are below 1 percent with this approach. However, unsafe pregnancy termination procedures continue to occur globally and have a much higher rate of morbidity and mortality.
•(See "First-trimester pregnancy termination: Uterine aspiration", section on 'Antibiotic prophylaxis'.)
Signs and symptoms
●Common signs and symptoms – These typically include pelvic and/or abdominal pain, uterine tenderness, purulent vaginal discharge, vaginal bleeding, and/or fever [12]. Vaginal bleeding may be recent or active, depending on whether the pregnancy has already passed.
●Severe infection and sepsis – As the name septic abortion implies, those with uterine infection can progress to severe infection that triggers life-threatening organ dysfunction caused by the host's response to infection. Markers of severe infection may include fever (>38.0°C) or hypothermia, tachypnea, tachycardia, and leukocytosis or leukopenia (table 1). Pain and/or tenderness out of proportion to physical examination findings may indicate necrotizing infection.
•(See "Necrotizing soft tissue infections".)
EVALUATION
Need for rapid recognition — Septic abortion can progress rapidly and be lethal. Therefore, any patient who presents with abdominal/pelvic pain, uterine tenderness, and fever in the setting of pregnancy loss, termination, or recent pregnancy should be evaluated quickly (algorithm 1). Individuals at particular risk for septic abortion include those with a history of unsafe abortion, uterine instrumentation, or prolonged vaginal bleeding [13]. Once recognized, the general approach includes empiric broad-spectrum intravenous (IV) antibiotics, IV fluid support, and surgical evacuation of the uterus (regardless of fetal cardiac activity) [4-6,12]; the speed and intensity of response vary with the hemodynamic stability of the patient, as discussed below. (See 'Management' below.)
Obtain targeted history — Patients presenting with infection in the setting of pregnancy loss may not be aware that they are or have recently been pregnant (eg, early pregnancy loss may be experienced as a late period). Additionally, some may have tried to interrupt the pregnancy without involving a medical professional or using unsafe methods and may not feel safe reporting the procedure or the pregnancy. In addition to asking about medical conditions, medications, and allergies, other questions include:
●Date of last menstrual period and whether the patient has regular periods (ie, approximately monthly). Individuals with irregular menses, such as those with polycystic ovary syndrome, may be less likely to know they are pregnant.
●If the patient is known to be pregnant.
●If the patient had a uterine procedure within a few weeks of presentation.
Perform laboratory evaluation — We perform the following studies for patients with septic abortion (algorithm 1):
●Blood cultures – Blood cultures, both aerobic and anaerobic, are performed to assess for bacteremia. We typically limit drawing blood cultures to patients presenting with fever and those with a clinical concern for bacteremia. Antibiotic selection should cover genital pathogens as well as organisms grown in blood culture, but not organisms cultured from products of conception, which often grow multiple organisms that reflect the range of vaginal microbiota.
•(See 'Start broad-spectrum intravenous antibiotics' below.)
•(See "Detection of bacteremia: Blood cultures and other diagnostic tests".)
•(See "Gram-negative bacillary bacteremia in adults", section on 'Management'.)
●STI testing – Tests for sexually transmitted infections (STIs), including gonorrhea, Chlamydia trachomatis, and trichomoniasis, are performed because these lower genital tract infections are risk factors for uterine infection. These tests can be performed on urine, vaginal, or cervical specimens. Additional information on screening tests for STIs can be found separately. (See "Screening for sexually transmitted infections", section on 'Screening methods'.)
●Serum tests for sepsis syndromes – Serum tests for sepsis syndrome include complete blood count with differential, lactate level, coagulation studies (prothrombin time/partial thromboplastin time and fibrinogen), and a complete metabolic panel (to evaluate renal function). (See "Sepsis syndromes in adults: Epidemiology, definitions, clinical presentation, diagnosis, and prognosis", section on 'Laboratory signs'.)
●Blood type and antibody screen – These are performed in case transfusion is needed. (See "Pretransfusion testing for red blood cell transfusion".)
●Urinalysis and urine culture – These are useful to exclude urinary tract infection and/or pyelonephritis. (See "Acute simple cystitis in adult and adolescent females", section on 'Clinical suspicion and evaluation'.)
Assess for complications of septic abortion — Complications of septic abortion may include acute respiratory distress syndrome (ARDS), hemolysis and/or disseminated intravascular coagulation (DIC), lactic acidosis, acute renal injury, toxic shock, necrotizing soft tissue infections, gas gangrene, and sepsis syndromes. Patients who are diagnosed with any of these may rapidly progress to hemodynamic instability and should be managed emergently and moved toward rapid surgical treatment as quickly as medically safe.
●(See "Acute respiratory distress syndrome: Clinical features, diagnosis, and complications in adults".)
●(See "Evaluation and management of disseminated intravascular coagulation (DIC) in adults".)
●(See "Causes of lactic acidosis", section on 'Type A lactic acidosis'.)
●(See "Nonoliguric versus oliguric acute kidney injury".)
Proceed with imaging if clinically stable
Ultrasound
Role of ultrasound to aid clinical decision-making — Ultrasound findings are not diagnostic for septic abortion; the decision to treat with antibiotics and evacuate the uterus is based on the patient's history and clinical evaluation findings.
Ultrasound imaging can support the diagnosis by showing retained products of conception or evidence of upper tract infection (eg, dilated fallopian tubes and/or tubo-ovarian abscess) [14], but normal ultrasound imaging does not exclude a septic abortion. Ultrasound measurement of endometrial thickness by itself does not predict the need for surgical intervention [15].
Common imaging findings — Information that is commonly obtained from ultrasound imaging includes:
●Presence or absence of embryonic or fetal tissues.
●Gestational age and presence/absence of cardiac activity (if an embryo or fetus is seen). The presence of a living embryo/fetus on ultrasound imaging does not exclude the possibility of septic abortion nor does it change the interventions needed to treat a patient with sepsis.
●Amount of intrauterine tissue, fluid, or air. If present, intrauterine tissue is evaluated for size in three planes and blood flow with color and spectral Doppler.
●Loss of well-defined endometrial myometrial interface and development of a thin hypoechoic rim in subserosal distribution.
●Enhanced myometrial vascularity. Postpartum patients may have increased myometrial vascularity even in the absence of intrauterine tissue, which can help support the diagnosis of recent pregnancy, and suggest septic abortion, if the history is unclear.
●Hydro/pyosalpinges or adnexal evolving inflammatory process suggestive of tubo-ovarian complex or abscess.
Computed tomography (CT) — CT is often the first-line imaging study performed for patients presenting to an emergency department with abdominal pain and concerns for infection.
●Potential findings – In general, CT findings are equally as nonspecific as ultrasound for patients with septic abortion. CT may demonstrate small amounts of gas in the endometrial cavity up to three weeks postpartum.
CT imaging can be useful if the inflammatory process has progressed to parametrial soft tissues, extended to the extrauterine pelvis, or caused septic thrombophlebitis. In hemodynamically stable patients, CT can help to exclude inflammatory processes other than gynecologic in origin, such as appendicitis or diverticulitis.
●Concern for necrotizing infection – While CT may demonstrate gas in the deep tissue indicating necrotizing or clostridial infections, lack of gas does not exclude this entity. Other imaging findings suggestive of Clostridium perfringens or Paeniclostridium sordellii infection include peritoneal and/or pleural effusions and signs of tissue edema or necrosis [11]. (See "Clostridial myonecrosis", section on 'Diagnosis'.)
DIAGNOSIS — Septic abortion is a clinical diagnosis made in patients who present with signs and symptoms of pelvic infection (uterine pain and tenderness, fever, vaginal bleeding) following pregnancy loss or termination up to 20 weeks gestation.
DIFFERENTIAL DIAGNOSIS — Other common causes of abdominal/pelvic pain and fever in pregnant or recently pregnancy individuals include (but are not limited to) postpartum endometritis, urinary tract infection, pyelonephritis, and appendicitis [13]. Less common causes for consideration include pelvic inflammatory disease (PID) and ectopic pregnancy.
●Postpartum endometritis – These individuals present with uterine pain and tenderness, fever, and related symptoms (nausea, fatigue) following delivery at 20 weeks gestation or greater. (See "Postpartum endometritis".)
●Urinary tract infection with or without pyelonephritis – Individuals with urinary tract infections often have pain with urination, urinary frequency, and urinary urgency in addition to pelvic pain and/or tenderness. Additional findings suggestive of upper tract infection include flank pain and fever. The urinary symptoms and abnormal urinalysis differentiate urinary tract infection from septic abortion.
•(See "Acute simple cystitis in adult and adolescent females".)
•(See "Acute complicated urinary tract infection (including pyelonephritis) in adults and adolescents".)
●Appendicitis – Appendicitis classically presents with right lower quadrant abdominal pain, lack of appetite (anorexia), and nausea and vomiting. Pelvic pain, tenderness, and low-grade fever may also be present, but the uterus itself is not tender in patients with appendicitis. (See "Acute appendicitis in adults: Clinical manifestations and differential diagnosis".)
●Pelvic inflammatory disease (PID) – PID is an acute infection of the upper genital tract that is typically initiated by a sexually transmitted infection (STI) and rare in pregnancy. (See "Pelvic inflammatory disease: Clinical manifestations and diagnosis", section on 'Patients at risk'.)
●Ectopic pregnancy – Ectopic pregnancy commonly presents with vaginal bleeding and/or pelvic pain in the first trimester of pregnancy. Signs and symptoms of infection may be present but are typically minor. (See "Ectopic pregnancy: Clinical manifestations and diagnosis".)
MANAGEMENT — Management of individuals with septic abortion includes rapid recognition of infection, initiation of broad-spectrum antibiotics and intravenous (IV) fluid, and removal of infected intrauterine tissue to achieve source control (algorithm 1) [12]. The urgency of these steps varies with the severity of the patient's presentation and hemodynamic stability.
Hemodynamically unstable patient — Patients who are hemodynamically unstable require emergency resuscitation (including airway, breathing, and circulatory support, with vasopressors and inotropes as needed), initiation of IV antibiotics, and urgent surgical evacuation of the uterus. If available, early consultation with an infectious disease specialist is suggested.
While these components are the same as for stable individuals, hemodynamically unstable individuals have the steps performed in rapid sequence so that surgical uterine evacuation can occur as quickly as possible to facilitate resuscitation.
●Resuscitation in an operative setting may aid the process.
●Patients with suspected infection with toxin-producing bacteria or uterine injury may require emergency progression to exploratory laparotomy and hysterectomy.
●Postoperative management in an intensive care unit may be required.
Stable patient — The cornerstones of treatment are the rapid restoration of perfusion, initiation of IV antibiotics, and surgical evacuation of the uterus (algorithm 1). The patient may require management in the emergency department or operating room setting to maximize resuscitation.
Begin intravenous fluids — Intravascular hypovolemia may be present, particularly in individuals with prolonged bleeding and/or evidence of sepsis syndrome, and rapid fluid resuscitation is warranted. One data-supported approach is rapid infusion of crystalloid fluid boluses of 30 mL/kg during the first one to three hours of resuscitation (assuming there is no evidence of pulmonary edema) [16-18]. Additional discussions of fluid selection, volume, and timing are presented separately. (See "Evaluation and management of suspected sepsis and septic shock in adults", section on 'Intravenous fluids (first three hours)'.)
Start broad-spectrum intravenous antibiotics — For patients with known or suspected septic abortion, we initiate broad-spectrum IV antibiotics [13,19]. The regimen is selected empirically as a specific pathogen is rarely if ever known at the time of presentation. Most infections arise from urogenital and gastrointestinal flora and include Gram-negative, Gram-positive, and anaerobic pathogens. Antibiotics should be initiated immediately but do not replace surgical management for source control. (See 'Epidemiology and microbiology' above.)
Commonly used regimens — The authors prefer the first empiric regimen listed below, although other regimens may be reasonable in an appropriate setting and in consultation with Infectious Disease specialists if available. Selection is based on patient infectious and medical history, drug allergies, drug availability, drug cost, and known antibiotic susceptibility patterns in the locale. A study of 84 patients with septic abortion reported the combination of intravenous ampicillin, gentamicin, and metronidazole was felt to have the highest likelihood of laboratory susceptibility results while piperacillin-tazobactam provided greatest single-agent microbial coverage [7,13]. However, the study did not report antimicrobial resistance patterns specific to this population. As high rates of Enterobacteriaceae resistance to ampicillin have been reported in many locales, broad-spectrum coverage may be empirically safer until culture and sensitivity data are available. Examples of broad-spectrum regimens for general intra-abdominal infections are presented in the table (table 2). (See "Antimicrobial approach to intra-abdominal infections in adults", section on 'High-risk community-acquired infections'.)
Patients with suspected toxin-producing infection or group A Streptococcus benefit from inclusion of clindamycin in their treatment regimen [20,21]. Patients with severe infections, those who do not respond to initial therapy, or individuals whose cultures document an unusual organism may benefit from early consultation with an Infectious Disease specialist. Antibiotics should be initiated immediately but do not replace surgical management for source control.
●Preferred by the authors – Piperacillin-tazobactam (4.5 g IV every eight hours) with or without vancomycin (inclusion of vancomycin is based on culture results and local antibiotic resistance patterns) [7,13,19]
●Alternatives [13]
•Imipenem (500 mg IV every six hours). This regimen may be useful for severely ill patients.
or
•Gentamicin (5 mg/kg/day IV) plus ampicillin (2 g IV every four hours) plus clindamycin (900 mg IV every eight hours)
or
•Gentamicin (5 mg/kg/day IV) plus ampicillin (2 g IV every four hours) plus metronidazole (500 mg IV every eight hours)
or
•Levofloxacin (500 mg IV daily) and metronidazole (500 mg IV every eight hours)
or
•Ticarcillin-clavulanate (3.1 g IV every four hours)
Alternative regimens — Based on the Centers for Disease Control and Prevention (CDC) Sexually Transmitted Diseases Treatment Guidelines' suggested drug treatment of pelvic inflammatory disease (PID), regimens consisting of cefoxitin or cefotetan, plus doxycycline and metronidazole, could also be reasonable, although these agents have not been specifically studied for septic abortion or severe intra-abdominal infections [22,23].
Oral regimens — In general, we do not use oral antibiotics for initial treatment of septic abortion because of insufficient data on their efficacy and safety in patients with severe infection of the uterus. However, we recognize that stable patients with isolated post-procedure endometritis may be candidates for oral outpatient therapy, in accordance with the US Centers for Disease Control and Prevention (CDC) guidelines for outpatient treatment of PID. Treatment regimens are discussed in related content.
●(See "First-trimester pregnancy termination: Uterine aspiration", section on 'Infection'.)
●(See "Pelvic inflammatory disease: Treatment in adults and adolescents".)
Evacuate the uterus — Patients with clinically symptomatic infection, even those who do not meet criteria for sepsis syndrome, require urgent surgical evacuation of the uterus (algorithm 1) because rapid source control is a critical step in management of infection [19]. Thus, expectant or medication management of retained uterine tissue are generally not advised [24,25].
●Timing – Uterine evacuation by aspiration is typically performed soon after initiation of IV antibiotics. While evidence-based consensus is lacking, we advise evacuation within four to six hours after presentation as this time frame allows initiation of antibiotics and fluids while the patient is stabilized.
●Technique – The technique for uterine aspiration is the same whether the patient experienced pregnancy loss or a complication of induced abortion. Gestational age of the pregnancy, if still present, generally guides the approach. As with all uterine aspiration procedures, we avoid sharp curettage [26,27]. Additional discussion of surgical management is presented in related content. (See "Pregnancy loss (miscarriage): Description of management techniques", section on 'Surgical management (uterine aspiration)'.)
●Ultrasound guidance – The authors use ultrasound guidance during the procedure to ensure all infected tissue is removed and to potentially reduce the risk of uterine perforation, which is more likely in an infected uterus. However, the procedure should not be delayed if an ultrasound is not immediately available. [26,27].
●Culture of retained tissue – Pregnancy tissue (products of conception) should be sent for aerobic and anaerobic culture as this may guide subsequent antibiotic choice. Culture of the uterus cavity is not indicated. Cultures from pregnancy tissue are typically contaminated with genital flora and grow multiple organisms. However, in the setting of intrauterine infection, the culture results may be helpful if a dominant or usual organism is identified or if there is lack of clinical improvement with the initial antibiotic regimen. (See "Pregnancy loss (miscarriage): Description of management techniques", section on 'Surgical management (uterine aspiration)'.)
●Risks – In the presence of infection, the main risks of uterine evacuation are bleeding, which can be massive, and uterine perforation.
•Massive hemorrhage – Massive hemorrhage can occur with uterine atony or vascular injury. The approach to managing bleeding is similar to managing hemorrhage after pregnancy termination or postpartum hemorrhage (for third trimester pregnancy) (figure 1). Massive transfusion protocols may be required as one part of the resuscitation efforts (algorithm 2).
-(See "Overview of pregnancy termination" and "Overview of pregnancy termination", section on 'Hemorrhage'.)
-(See "Overview of postpartum hemorrhage".)
-(See "Massive blood transfusion".)
•Uterine perforation – Perforation can lead to injury of abdominal or pelvic organs or vasculature. (See "Uterine perforation during gynecologic procedures".)
Duration of antibiotic treatment — Duration of antibiotic treatment varies based on the patient's hemodynamic stability, clinical response, and culture results, particularly blood culture information. Minimum criteria for stopping intravenous antibiotics include complete control of the infection's source, significant patient clinical improvement, and significant improvement of end-organ changes. Patients may then be switched to oral medication to complete 10 to 14 days of additional treatment [19].
Postoperative care — Postoperatively, patients with septic abortion require frequent monitoring and ongoing management (algorithm 3).
Frequent monitoring — After uterine aspiration, the patient continues IV antibiotics and fluid. We monitor patients continuously and reassess them hourly for improvement or lack thereof. Evidence of clinical improvement can be seen as early as six hours after uterine evacuation combined with IV fluid resuscitation and antibiotics [28].
Patients who improve — Patients who improve are transitioned to routine postoperative care protocols, and IV antibiotics are tailored to the culture results (algorithm 3). If the culture does not identify specific organisms, then broad-spectrum regimens that include coverage of anaerobic organisms are maintained. Intravenous antibiotics are continued until the patient's uterus has been evacuated and there is clinical evidence of resolving infection (eg, afebrile for 48 hours, reduced pelvic tenderness). The patient is then transitioned to oral antibiotics to complete a 10- to 14-day course [19]. One oral antibiotic regimen that is extrapolated from treatment of patients with PID includes [22]:
●Doxycycline 100 mg orally twice a day for 14 days
and
●Metronidazole 500 mg orally twice a day for 14 days
Patients who do not improve or who worsen — Following uterine aspiration, patients who do not adequately improve and/or who develop sepsis syndrome, acute respiratory distress syndrome (ARDS), disseminated intravascular coagulation (DIC), evidence of organ failure, peritonitis, or pelvic abscess proceed with emergency laparotomy and hysterectomy (algorithm 3) [13]. IV antibiotics and fluid resuscitation are continued. If readily available, abdominal imaging with radiograph or computed tomography (CT) can be helpful to assess for free air in the abdomen and/or gas in the myometrium, which suggest clostridial infection. This is a devastating disease progression and by definition, is occurring in young, reproductive-age females. A desire to preserve future fertility should not prevent performing a life-saving hysterectomy.
●(See "Acute respiratory distress syndrome: Clinical features, diagnosis, and complications in adults".)
●(See "Evaluation and management of disseminated intravascular coagulation (DIC) in adults".)
●(See "Causes of lactic acidosis", section on 'Type A lactic acidosis'.)
●(See "Nonoliguric versus oliguric acute kidney injury".)
EXPLORATORY LAPAROTOMY AND HYSTERECTOMY — Emergency laparotomy and hysterectomy may be necessary to treat infection that does not respond (or spreads) or complications of uterine evacuation.
Specific scenarios include:
●Infection with toxin-producing bacteria – These most commonly include Staphylococcus aureus, group A Streptococcus, Clostridioides (formerly Clostridium) species, and strains of Escherichia coli. Such infection may be suspected or confirmed by Gram stain and culture, suggested by imaging studies showing gas in tissues, the physical examination findings of crepitance or significant tenderness to palpation, or by features of toxic shock.
•(See "Staphylococcal toxic shock syndrome".)
•(See "Invasive group A streptococcal infection and toxic shock syndrome: Treatment and prevention".)
•(See "Clostridial myonecrosis" and "Clostridial myonecrosis", section on 'Treatment'.)
●Evidence of myonecrosis – Hysterectomy is required for an avascular wood-like uterus because antibiotics cannot penetrate necrotic tissue.
•(See "Clostridial myonecrosis".)
•(See "Surgical management of necrotizing soft tissue infections".)
●Significant intraperitoneal infection – This can include tubo-ovarian or other abscess(es).
•(See "Management and complications of tubo-ovarian abscess".)
●Massive hemorrhage – Hysterectomy can be a life-saving procedure for massive bleeding from vascular injury (uterus or pelvic vessels), uterine atony, or coagulopathy (algorithm 2). Management approaches are similar to postpartum hemorrhage and massive blood loss.
•(See "Overview of postpartum hemorrhage".)
•(See "Massive blood transfusion".)
●Perforation or rupture of the uterus – These can result from uterine instrumentation or delivery.
•(See "Uterine perforation during gynecologic procedures", section on 'Abdominal exploration'.)
SOCIETY GUIDELINE LINKS — Links to society and government-sponsored guidelines from selected countries and regions around the world are provided separately. (See "Society guideline links: Pregnancy loss (spontaneous abortion)" and "Society guideline links: Pregnancy termination".)
INFORMATION FOR PATIENTS — UpToDate offers two types of patient education materials, "The Basics" and "Beyond the Basics." The Basics patient education pieces are written in plain language, at the 5th to 6th grade reading level, and they answer the four or five key questions a patient might have about a given condition. These articles are best for patients who want a general overview and who prefer short, easy-to-read materials. Beyond the Basics patient education pieces are longer, more sophisticated, and more detailed. These articles are written at the 10th to 12th grade reading level and are best for patients who want in-depth information and are comfortable with some medical jargon.
Here are the patient education articles that are relevant to this topic. We encourage you to print or e-mail these topics to your patients. (You can also locate patient education articles on a variety of subjects by searching on "patient info" and the keyword(s) of interest.)
●Basics topics (see "Patient education: Pregnancy loss (The Basics)" and "Patient education: Bleeding in early pregnancy (The Basics)" and "Patient education: Abortion (The Basics)")
●Beyond the Basics topics (see "Patient education: Pregnancy loss (Beyond the Basics)" and "Patient education: Abortion (pregnancy termination) (Beyond the Basics)")
SUMMARY AND RECOMMENDATIONS
●Clinical presentation and diagnosis – Septic abortion is a clinical diagnosis made in patients who present with signs and symptoms of uterine infection, including abdominal or pelvic pain, uterine tenderness, purulent vaginal discharge, vaginal bleeding, and/or fever following pregnancy loss or termination. (See 'Clinical features' above.)
•Incidence – The incidence of septic abortion is not fully known as it encompasses infection following both spontaneous pregnancy loss and pregnancy termination (medication and surgical). (See 'Epidemiology and microbiology' above.)
•Microbiology – Most infections arise from vaginal flora and include anaerobic pathogens. Commonly identified organisms include Enterobacteriaceae, streptococci, staphylococci, enterococci, and Group A Streptococcus infections. (See 'Epidemiology and microbiology' above.)
●Evaluation – Septic abortion can progress rapidly and be lethal. Therefore, any patient who presents with abdominal/pelvic pain, uterine tenderness, and fever in the setting of pregnancy loss or recent pregnancy should be evaluated quickly with a targeted history, including discussion of last menstrual period, laboratory evaluation, and ultrasound imaging (algorithm 1). In addition, some patients may not be aware they are or have been pregnant or may not want to report a pregnancy or having undergone an unsafe abortion. (See 'Evaluation' above.)
●Management – The cornerstones of treatment are the rapid restoration of perfusion with intravenous (IV) fluid, initiation of IV antibiotics, and surgical evacuation of the uterus (algorithm 1). Antibiotics should be initiated immediately but do not replace surgical management for source control. (See 'Management' above.)
•Hemodynamically unstable patients – Patients who are hemodynamically unstable require emergency resuscitation (including airway, breathing, and circulatory support, with vasopressors and inotropes as needed), initiation of IV antibiotics, and urgent surgical evacuation of the uterus. Simultaneous evaluation and treatment is typically done in an intensive care or operative setting. While the treatment components are the same as presented for stable individuals below, the steps are performed simultaneously and in an emergency fashion so that surgical uterine evacuation can occur as quickly as possible.
•Stable patients
-Intravenous fluid – Intravascular hypovolemia may be present, particularly in individuals with prolonged bleeding and/or evidence of sepsis syndrome, and rapid fluid resuscitation is required. There is no single approach to fluid choice or infused volume; treatment is tailored to the clinical status of the patient. (See 'Begin intravenous fluids' above and "Evaluation and management of suspected sepsis and septic shock in adults", section on 'Intravenous fluids (first three hours)'.)
-Broad-spectrum intravenous antibiotics – Prompt antimicrobial therapy is required for the treatment of septic abortion but does not replace surgical management for source control. For most patients with septic abortion in which the pathogens are unknown, we suggest empiric treatment with piperacillin-tazobactam 4.5 g IV every eight hours rather than other regimens (Grade 2C). However, alternative regimens are reasonable and selected based on patient allergies, drug availability, and cost. Antibiotic coverage may be tailored pending culture results. (See 'Commonly used regimens' above.)
-Surgical uterine evacuation – Patients with clinically symptomatic infection, even those who do not meet criteria for sepsis syndrome, require urgent surgical evacuation of the uterus. The authors use ultrasound guidance during the procedure to ensure all infected tissue is removed and to potentially reduce the risk of uterine perforation, which is more likely in the setting of infection. Expectant or medication management of retained uterine tissue is generally not advised because of the potentially life-threatening nature of septic abortion. (See 'Evacuate the uterus' above.)
●Postoperative care – After uterine aspiration, IV antibiotics and fluid are continued. We monitor patients continuously and reassess them hourly for improvement or lack thereof (algorithm 3). (See 'Postoperative care' above.)
•Adequate improvement – Patients who improve are moved to routine postoperative care protocols (algorithm 3). Antibiotic therapy is tailored based on culture results and clinical response. Patients with adequate clinical improvement are then transitioned to oral antibiotics. (See 'Patients who improve' above.)
•Inadequate improvement or clinical worsening – Patients who do not adequately improve and/or who develop sepsis syndrome, acute respiratory distress syndrome (ARDS), disseminated intravascular coagulation (DIC), evidence of organ failure, peritonitis, or pelvic abscess proceed to laparotomy with possible hysterectomy (algorithm 3). (See 'Patients who do not improve or who worsen' above.)
●Laparotomy and/or hysterectomy – Clinical scenarios that warrant laparotomy include concern for extensive infection/abscess, severe vascular injury (uterus or pelvic vessels), and massive hemorrhage from uterine atony or coagulopathy. Hysterectomy is done as a life-saving procedure for either bleeding and/or infection. (See 'Exploratory laparotomy and hysterectomy' above.)
ACKNOWLEDGMENTS — The UpToDate editorial staff acknowledges Togas Tulandi, MD, MHCM, and Haya M Al-Fozan, MD, who contributed to an earlier version of this topic review.
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