Reproductive · Obstetric Complications
The facts most likely to be tested
Septic abortion is defined as a spontaneous or induced abortion complicated by intrauterine infection.
The classic clinical triad consists of fever, abdominal pain, and foul-smelling vaginal discharge.
Physical examination typically reveals cervical motion tenderness and a boggy, tender uterus.
The most common causative pathogens are polymicrobial, including Escherichia coli, Group B Streptococcus, and Staphylococcus aureus.
Initial management requires hemodynamic stabilization followed by broad-spectrum intravenous antibiotics.
Definitive treatment necessitates prompt surgical evacuation of the uterus via suction curettage to remove the source of infection.
Failure to perform uterine evacuation in the setting of retained products of conception leads to septic shock and multiorgan failure.
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A 24-year-old G1P0 woman at 10 weeks gestation presents to the emergency department with a 2-day history of fever, chills, and lower abdominal pain. She admits to attempting an unsafe, non-medical termination of pregnancy one week ago. On physical exam, she is febrile at 102.4°F and tachycardic. Pelvic examination reveals purulent, foul-smelling vaginal discharge and significant cervical motion tenderness. The uterus is tender to palpation and enlarged for gestational age.
What is the most appropriate next step in management?
Broad-spectrum intravenous antibiotics and prompt surgical evacuation of the uterus.
The patient presents with the classic signs of septic abortion; the most critical management steps are stabilizing the patient with antibiotics and surgically removing the infected products of conception to prevent progression to septic shock.
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Etiology / Epidemiology
Infection of the products of conception following retained tissue or instrumentation. High risk in illegal/unsafe abortions or prolonged rupture of membranes.
Clinical Manifestations
Triad of fever, abdominal pain, and foul-smelling vaginal discharge. Uterine tenderness is the pathognomonic physical exam finding.
Diagnosis
Clinical diagnosis supported by pelvic ultrasound showing retained products. Leukocytosis with left shift is typical.
Treatment
Immediate broad-spectrum antibiotics and surgical evacuation (D&C). Do not delay surgery for imaging.
Prognosis
Risk of septic shock and multiorgan failure. Early intervention prevents Asherman syndrome and infertility.
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Epidemiology & Etiology
Occurs when pathogenic bacteria ascend from the lower genital tract into the uterus. Primary risk factors include retained products of conception (RPOC), recent instrumentation, or septic incomplete abortion. It is a life-threatening emergency requiring rapid recognition.
Pertinent Anatomy
The cervical os remains open in incomplete or septic abortion, providing a direct portal for ascending infection. The uterus is the primary site of infection, often manifesting as uterine tenderness on bimanual exam.
Pathophysiology
Infection triggers a systemic inflammatory response syndrome (SIRS). Endotoxins from gram-negative organisms (e.g., E. coli) lead to vasodilation and capillary leak. If untreated, this progresses to septic shock, disseminated intravascular coagulation (DIC), and renal failure.
Clinical Manifestations
Patients present with fever >38°C, chills, and lower abdominal pain. Physical exam reveals foul-smelling vaginal discharge and significant uterine tenderness. Hypotension and tachycardia are red flags for impending septic shock.
Diagnosis
Diagnosis is primarily clinical. Pelvic ultrasound is the gold standard to identify retained products of conception (echogenic mass). Laboratory findings include leukocytosis (>15,000/mm³) and elevated inflammatory markers.
Treatment
Stabilize the patient with IV fluids and initiate broad-spectrum antibiotics (e.g., ampicillin/sulbactam plus gentamicin). Perform suction curettage (D&C) promptly to remove the source of infection. Hysterectomy is reserved for cases of uterine gangrene or refractory infection.
Prognosis
Prompt evacuation is critical to prevent septic shock and death. Long-term sequelae include Asherman syndrome (intrauterine adhesions) and chronic pelvic pain. Monitor for DIC and acute kidney injury.
Differential Diagnosis
Ectopic pregnancy: positive pregnancy test with adnexal mass
Appendicitis: localized RLQ pain without foul discharge
Pelvic inflammatory disease: usually bilateral adnexal tenderness without pregnancy
Endometritis: postpartum onset rather than post-abortion
Gastroenteritis: associated with diarrhea and vomiting