[Septic abortion with massive coagulopathy and subsequent acute hysterectomy].

Septic abortion is a rare, but potentially life-threatening condition. Quick diagnosis and treatment is essential for the outcome. This case report describes a healthy 34-year-old woman who was admitted with abdominal pain, fever and an ongoing spontaneous abortion at gestational age week 13 + 6 days. During evacuation severe bleeding and coagulopathy was seen. She was treated with multiple coagulation products but due to a life-threatening situation an acute hysterectomy was performed. She was discharged after nine days.

Induced abortion.

Abortion is common. Data on abortion rates are inexact but can be used to explore trends. Globally, the estimated rate in the period 2010-2014 was 35 abortions per 1000 women (aged 15-44 years), five points less than the rate of 40 for the period 1990-1994. Abortion laws vary around the world but are generally more restrictive in developing countries. Restrictive laws do not necessarily deter women from seeking abortion but often lead to unsafe practice with significant mortality and morbidity. While a legal framework for abortion is a prerequisite for availability, many laws, which are not evidence based, restrict availability and delay access. Abortion should be available in the interests of public health and any legal framework should be as permissive as possible in order to promote access. In the absence of legal access, harm reduction strategies are needed to reduce abortion-related mortality and morbidity. Abortion can be performed surgically (in the first trimester, by manual or electric vacuum aspiration) or with medication: both are safe and effective. Cervical priming facilitates surgery and reduces the risk of incomplete abortion. Diagnosis of incomplete abortion should be made on clinical grounds, not by ultrasound. Septic abortion is a common cause of maternal death almost always following unsafe abortion and thus largely preventable. While routine follow-up after abortion is unnecessary, all women should be offered a contraceptive method immediately after the abortion. This, together with improved education and other interventions, may succeed in reducing unintended pregnancy.

Maternal near miss and mortality due to postpartum infection: a cross-sectional analysis from Rwanda.

BACKGROUND: The objective of this study is to evaluate 'near miss' and mortality in women with postpartum infections. METHODS: We performed a retrospective review of all patients referred to the University Teaching Hospital of Kigali (CHUK) between January 2012 and December 2013. We identified 117 patients with postpartum infections. Demographic data, length of admission, location of referral, initial surgery and subsequent treatment modalities including antibiotic administration and secondary surgery were recorded. The primary outcome of interest was a composite of maternal mortality and "near miss" defined as more than one laparotomy with/without hysterectomy and prolonged hospitalization. RESULTS: Diagnoses at CHUK were: pelvic peritonitis (56 %), deep surgical site infection including fasciitis (17 %), and endometritis (15 %). The primary procedures performed prior to transfer were: cesarean section (81 %), septic abortion management (12 %), and vaginal delivery (7 %). Antibiotics were initiated prior to transfer in 66 % of women. Surgery was required in 73 % of patients. Hysterectomies were performed in 22 % of patients. Maternal death occurred in 5 % of the patient population. The primary outcome of severe maternal morbidity and mortality occurred in 90 patients (77 %). CONCLUSION: Peritonitis-primarily as a result of cesarean deliveries-is associated with significant morbidity and mortality in our population.

Treating spontaneous and induced septic abortions.

Worldwide, abortion accounts for approximately 14% of pregnancy-related deaths, and septic abortion is a major cause of the deaths from abortion. Today, septic abortion is an uncommon event in the United States. The most critical treatment of septic abortion remains the prompt removal of infected tissue. Antibiotic administration and fluid resuscitation provide necessary secondary levels of treatment. Most young physicians have never treated septic abortion. Many obstetrician-gynecologists experience, or plan to experience, global health activities and will likely care for women with septic abortion. Thus, updated knowledge of the pathophysiology, clinical presentation, microbes, and proper treatment is needed to optimally treat this emergency condition when it exists. The pathophysiology of septic abortion involves infection of the placenta, especially the maternal villous space that leads to a high frequency of bacteremia. Symptoms and signs range from mild to severe. The microbes involved are usually common vaginal bacteria, including anaerobes, but occasionally potentially very serious and lethal infection is caused by bacteria that produce toxins. The primary treatment is early curettage to remove infected and devitalized tissue even in the face of continued fetal heart tones. Important secondary treatments are the administration of fluids and antibiotics. Updated references of sepsis and septic shock are reviewed.

An audit of the initial resuscitation of severely ill patients presenting with septic incomplete miscarriages at a tertiary hospital in South Africa.

BACKGROUND: Septic incomplete miscarriages remain a cause of maternal deaths in South Africa. There was an initial decline in mortality when a strict protocol based approach and the Choice of Termination of Pregnancy Act in South Africa were implemented in this country. However, a recent unpublished audit at the Pretoria Academic Complex (Kalafong and Steve Biko Academic Hospitals) suggested that maternal mortality due to this condition is increasing. The objective of this investigation is to do a retrospective audit with the purpose of identifying the reasons for the deteriorating mortality index attributed to septic incomplete miscarriage at Steve Biko Academic Hospital. METHODS: A retrospective audit was performed on all patients who presented to Steve Biko Academic Hospital with a septic incomplete miscarriage from 1(st) January 2008 to 31(st) December 2010. Data regarding patient demographics, initial presentation, resuscitation and disease severity was collected from the "maternal near-miss"/SAMM database and the patient's medical record. The shock index was calculated for each patient retrospectively. RESULTS: There were 38 SAMM and 9 maternal deaths during the study period. In the SAMM group 86.8% and in the maternal death group 77.8% had 2 intravenous lines for resuscitation. There was no significant improvement in the mean blood pressure following resuscitation in the SAMM group (p 0.67), nor in the maternal death group (p 0.883). The shock index before resuscitation was similar in the two groups but improved significantly following resuscitation in the SAMM group (p 0.002). Only 31.6% in the SAMM group and 11.1% in the maternal death group had a complete clinical examination, including a speculum examination of the cervix on admission. No antibiotics were administered to 21.1% in the SAMM group and to 33.3% in the maternal death group. CONCLUSION: The strict protocol management for patients with septic incomplete miscarriage was not adhered to. Physicians should be trained to recognise and react to the seriously ill patient. The use of the shock index in the identification and management of the critically ill pregnant patient needs to be investigated.

Acute kidney injury complicating septic unsafe abortion: clinical course and treatment outcomes of 44 cases.

AIM: The aim of this study was to present the clinical course and treatment outcomes of patients with acute kidney injury (AKI) after septic unsafe abortion. MATERIAL AND METHODS: Medical records of patients with AKI after septic unsafe abortion admitted at Khon Kaen Hospital between January 2003 and December 2009 were reviewed. RESULTS: Forty-four patients with an average age of 24.3 years were included and 25% were teenage girls. The most common method of induced abortion was transvaginal chemical injection (81.8%). One patient had a hysterectomy due to severe peritonitis and sepsis that was not responsive to medical treatment. AKI developed on day 4.5 ± 3.6 with the range of onset 1-14 days after induced abortion. Oliguric AKI was present in 70.4% of patients with the mean duration of oliguria of 7.4 ± 5 days. Seventeen patients required dialysis. The mortality rate was 9%. The average duration of recovery from AKI was 24.8 ± 16.6 days. CONCLUSIONS: Conservative treatment of AKI-related septic unsafe abortion was dialysis without hysterectomy. The treatment results were minimal morbidity and mortality. Conservative management may be a better alternative to hysterectomy for the treatment of septic unsafe abortion with AKI. However the current study was a retrospective study, and we were not able to obtain certain follow-up data, such as fertility outcomes after recovery. Therefore, further study of these issues should be considered.

Clinical characteristics and outcomes of obstetric patients requiring ICU admission.

OBJECTIVES: To review a series of critically ill obstetric patients admitted to our ICU to assess the spectrum of disease, required interventions, and fetal/maternal mortality, and to identify conditions associated with maternal death. DESIGN: Retrospective cohort. SETTING: Medical-surgical ICU in a university-affiliated hospital. PATIENTS: Pregnant/postpartum admissions between January 1, 1998, and September 30, 2005. INTERVENTIONS: None. MEASUREMENTS AND RESULTS: We studied 161 patients (age, 28 +/- 9 years; mean gestational age, 29 +/- 9 weeks) [mean +/- SD], constituting 10% of 1,571 hospital admissions. APACHE (acute physiology and chronic health evaluation) II score was 14 +/- 8, with 24% predicted mortality; sequential organ failure assessment score was 5 +/- 3; and therapeutic intervention scoring system at 24 h was 25 +/- 9. Forty-one percent of patients required mechanical ventilation (MV). ARDS, shock, and organ dysfunction were present in 19%, 25%, and 48% of patients, respectively. Most patients (63%) were admitted postpartum, and 74% of admissions were of obstetric cause. Hypertensive disease (40%), major hemorrhage (16%), septic abortion (12%), and nonobstetric sepsis (10%) were the principal diagnoses. Maternal mortality was 11%, with multiple organ dysfunction syndrome (44%) and intracranial hemorrhage (39%) as main causes. There were no differences in death rate in patients admitted for obstetric and nonobstetric causes. Fetal mortality was 32%. Only 30% of patients received antenatal care, which was more frequent in survivors (33% vs 6% nonsurvivors, p = 0.014). CONCLUSIONS: Although ARDS, organ failures, shock, and use of MV were extremely frequent in this population, maternal mortality remains within an acceptable range. APACHE II overpredicted mortality in these patients. Septic abortion is still an important modifiable cause of mortality. Efforts should concentrate in increasing antenatal care, which was clearly underprovided in these patients.

Septic abortion: a review of social and demographic characteristics.

Septic abortion is a significant health problem with short- and long-term complications that affect the quality of life of those fortunate enough to avoid mortality. Both spontaneous and induced abortion can result in septic complications, with the latter disproportionately higher. Its incidence is high in environments with restrictive abortion laws, as clandestine procedures by non-doctors in unhygienic settings are prevalent. This study shows that it is still more common among teenagers and mainly performed by health professionals, which means that health care interventions should be re-evaluated and appropriately directed to preserve the reproductive health status of this vulnerable population.

Women with septic abortion: who, how and why? A prospective study from tertiary care hospital in India.

A prospective descriptive interview based hospital study was carried on 47 women admitted with septic abortion to evaluate their psychosocial, demographic and clinical profile These women were predominantly parous (75%), hindus (60%), between 20-30 years of age (60%) and mostly married (91.4%) house wives (63.8%). More than 90% already had one or more male child. The contraceptive use was dismally low (23.4%). Their knowledge about legalisation, place and persons authorized to conduct abortions was very less, however large majority (87%) underwent abortions within 3 months of pregnancy. Large family, poverty and spacing were the main reasons cited for abortions. Abdominal pain, fever, genital bleeding, diarhoea and abdominal distension were presenting clinical features in order of frequency. Advanced sepsis and associated medical and surgical complications were present in more than half the patients and 6% succumbed to these problems. The current experience was an eye opener for most of them and changed their future attitude. Hence education, economic prosperity, easy access to reproductive health facilities and institutional management of sepsis is the key to make abortions safe.

Morbilidad y mortalidad del aborto séptico en el Hospital Bertha Calderón Roque, enero 2003-diciembre 2004 / Morbilidad and mortality of the septic abortion in the Hospital Bertha Asleep Calderón, January 2003-December 2004

Se realizó un estudio descriptivo de corte transversal, en el Hospital Bertha Calderón Roque en el período comprendido de enero 2003 a diciembre 2004, para investigar la morbi-mortalidad del aborto septico de las pacientes atendidas en el mismo. Se estudiaron 46 pacientes que constituyeron el universo, seleccionándose una muestra de 37 mujeres que cumplieron con los criterio s de trabajo. Los principales resultados fueron que el total de pacientes ingresadas con diagnóstico de aborto, el 4.13 porciento tenían diagnóstico de aborto séptico de las cuales reportaron 4 fallecidas (10.8 porciento)las cuales se realizaon la interrupción del embarazo en condiciones higiénicas inadecuadas. La mayor incidencia del mismo se observó en el grupo de edad comprendido entre los 20-24 años de edad (43.2 porciento), siendo mas frecuente en las mujeres de unión hecho estable (54 porciento), la mayoria de origen urbano (70.3 porciento). El 83.7 porciento eran amas de casas, 78.3 no tenían antecendentes de aborto y el 54 porciento de ellas tenían de 2-4 partos anteriores. El estado general de las pacientes ingresadas al hospital era condicion grave en su mayoria 56.7 porciento, obsevándose que el 73 porciento las condiciones donde fue realizada la interrupción de la gestación fue inadecuada. Tanto las pacientes en condiciones graves como muy graves fueron manejada con antibiótico terapia en los casos graves además se realizó legrado uterino y en los mas graves con intervención quirúrgica (histectormia total abdominal). Las principales complicaciones médicas presente por abor séptico fueron: shock séptico, anemia, endomiometritis y CID. La disminución de la mortalidad por aborto séptico encontrada en este estudio respecto a años anteriores, se considera se debe a los adelantos cientificos como mejoria en el ambiente quirúrgico, gran gama de antibióticos y aumento de recursos farmacológicos para abortar...

The clinical course of patients with septic abortion admitted to an intensive care unit.

OBJECTIVE: The purpose of this study was to describe the clinical course, complications, and outcome of patients with septic abortion admitted to the intensive care unit (ICU). DESIGN, SETTING, AND PATIENTS: In this retrospective study, the records of 63 patients with septic abortion admitted to the ICU of a university hospital in Argentina between 1985 and 1995 were reviewed. RESULTS: The mean age of the patients was 28.5 years, and 33% had had previous abortions. The mean gestational age was 10.5 weeks. The first ICU day Acute Physiology and Chronic Health Evaluation (APACHE) II mean score was 13.9. Acute renal failure developed in 73% (46 of 63) of the patients, disseminated intravascular coagulation (DIC) in 31% (15 of 49), and septic shock in 32% (20 of 63). Blood cultures were positive in 24% (15 of 62). Twelve patients died (19%). Eight of the deaths occurred during the first 48 h of the ICU admission. Compared with survivors, non-survivors had higher median number of organ failures (1.0 vs 4.0, p<0.0001), mean first ICU day SOFA scores (6.6 vs 10.0, p=0.0059), and mean APACHE II scores (12.7 vs 20.2, p=0.0003), and were more likely to have septic shock (18 vs 92%, p<0.0001), and receive dopamine (37 vs 83%, p=0.0040), mechanical ventilation (8 vs 83%, p<0.0001), and pulmonary artery catheter (8 vs 41%, p=0.0026). CONCLUSIONS: Although it is an avoidable complication, septic abortion requiring admission to the ICU is associated with high morbidity and mortality.

Clostridium welchii infection following amniocentesis: a case report and review of the literature.

We report a case of severe Clostridium welchii infection following amniocentesis with septicaemia, haemolysis, DIC, pulmonary oedema and renal failure. Full recovery occurred following aggressive conservative management using antibiotics, endometrial curettage and intensive monitoring. The patient retained her uterus and had a successful pregnancy two years later although caesarean section for uterine rupture was required. Conservative management with conservation of the uterus and ovaries may be a safe and effective option in the management of severe Clostridium infections, using antibiotics, endometrial curettage and multidisciplinary team input.

The impact of the Lagos manual vacuum aspiration (MVA) training courses on medical education.

The Department of Obstetrics and Gynaecology, College of Medicine, University of Lagos commenced training programmes in the use of manual Vacuum Aspiration (MVA) for the treatment of septic abortion in 1989. The courses were evaluated using pre-tests and post-tests, and those of the participants from the first 5 years were analysed. 142 doctors and 72 nurses were trained from teaching hospitals, parastatal and private hospitals. The results of 154 participants (71%) were recovered and analysed. The training courses significantly increased the medical knowledge of both doctors and nurses; those from the Teaching Hospitals appearing to gain more. The amount of knowledge gained by those from the private sector, although showing a statistically significant increase was much less than the other participants. More emphasis should be placed on improving the performance of those from the private sector.

Septic abortion.

PIP: Abortion-related deaths, which account for 47% of total maternal mortality in the world, result primarily from sepsis and are widespread in developing countries where abortion is illegal or inaccessible. Septic abortion offers opportunities for prevention on the primary, secondary, and tertiary level of medial care. Primary prevention of septic abortion encompasses the provision of effective contraception, provision of safe and legal abortion in cases of contraceptive failure, and appropriate medical management of abortion. Secondary prevention involves the prompt diagnosis of endometriosis and effective treatment to avert more serious infection. The diagnosis of septic abortion should be considered when women of reproductive age present to health facilities with vaginal bleeding, lower abdominal pain, and fever. Tertiary prevention is aimed at avoiding the serious complications of postabortal infection, including hysterectomy and death. Women with high fever, pelvic peritonitis, and tachycardia should undergo uterine evacuation and parental antibiotic therapy. Supportive care for cardiovascular system and other organs may be essential. The medical technology needed to avert serious complications and deaths from septic abortion is available. Lacking is a political commitment on the part of many governments and health care agencies to address this avoidable contributor to maternal morbidity and mortality.^ieng

[Current concepts in the pathogenesis and treatment of abortion and septic shock. II. The physiopathological bases and outlook in the management of septic shock]. / Conceptos actuales en la patogénesis y tratamiento del aborto y el choque séptico. Parte II. Bases fisiopatológicas y perspectivas en el manejo del choque séptico.

The septic shock has a low frequency in the gynecologic-obstetric patients, nevertheless several obstetric conditions like: septic abortion, chorioamnionitis or puerperal infections can be complicated with this syndrome. The infections cause near 20% of the maternal deaths. Because the high morbidity and mortality of the patients with septic shock is necessary to have an actual knowledge of its pathogenesis and treatment. Any person can be infected but only few of them will develop a septic shock, the response of the host to the microorganisms is the critical point for the develop of this syndrome. Many studies had showed the importance of the bacterial endotoxin and the tumoral necrosis factor as mediators of septic shock. The treatment include: control of the infectious process, restoration of tissue perfusion pressure, restoration of blood volume, use of inotropic agents and general support measures. The role of monoclonal antibodies against endotoxin in the management of Gram-negative sepsis is still ignored, but there are several studies that support its use.

Conceptos actuales en la patogénesis y tratamiento del aborto y el choque séptico: Parte II. Bases fisiopatológicas y perspectivas en el manejo del choque séptico / Currente concepts on pathogenesis and treatment of abortion and septic shock: Part II. Physiopathologic bases and perspectives in the management of septic shock

El choque séptico (CHS) es un evento poco frecuente en las pacientes gineco-obstétricas, no obstante diversas condiciones como el aborto séptico, las corioamnioitis, y las infecciones puerperales pueden complicarse con este síndrome. Los problemas infecciosos representan cerca de 20 por ciento de las muertes maternas. Debido a la alta morbilidad que el CHS condiciona, es necesario tener un conocimiento actualizado del mismo. No obstante que cualquier individuo puede padecer una infección, la respuesta del hospedero a los microporganismos invasores es el punto crítico para el desarrollo del CHS. Múltiples evidencias han mostrado la importancia de las endotoxinas bacterianas y del factor de necrosis tumoral en la patogénesis de este síndrome. El manejo incluye: control de proceso infecciosos, mantenimiento de un aporte adecuado de 02 a los tejidos, uso de agentes inotrópicos y medidas de soporte general. El uso de anticuerpos monoclonales contra endotoxinas es la perspectiva de tratamiento más promisoria, aunque hasta el momento acutal no ha sido demostrada una eficacia real

[Current concepts in the pathogenesis and treatment of abortion and septic shock I. The epidemiology, pathogenesis and management of septic abortion]. / Conceptos actuales en la patogénesis y tratamiento del aborto y el choque séptico. Parte I. Epidemiología, patogénesis y manejo del aborto séptico.

In view of the illegal status induced abortion, it is difficult to determine the degree to which it is practiced. In our country there are a great inconsistency in the statistics on the number of abortions and the number of maternal deaths due to this cause. The principal complication of the illegal induced abortion is the septic abortion, with an uncontrolled bacterial infection and systemic complications that dominate the clinical picture. The mortality of the septic abortion is elevated, in the majority of cases due to septic shock. The treatment consist on antimicrobial agents and early surgery. A reduction on the number of illegal abortions will decrease significantly the number of septic abortion's cases.