Septic miscarriage with toxic shock syndrome and disseminated intravascular coagulation (DIC): The role of surgery, recombinant activated factor VII and intravenous immunoglobulin (IVIG).

Severe sepsis with multi-organ failure is associated with a high mortality rate. This case report highlights the challenges and modalities available in the management of a lady with refractory shock and disseminated intravascular coagulation (DIC) due to toxic shock syndrome (TSS) from genital tract sepsis. Early surgical intervention to remove the source of infection, the use of recombinant activated factor VII to treat intractable disseminated intravascular coagulation and intravenous immunoglobulin to neutralise the circulating exotoxins, have been employed and shown to drastically improve outcomes.

Incidence and determinants of severe maternal morbidity: a transversal study in a referral hospital in Teresina, Piaui, Brazil.

BACKGROUND: Maternal near miss (MNM) investigation is a useful tool for monitoring standards for obstetric care. This study evaluated the prevalence and the determinants of severe maternal morbidity (SMM) and MNM in a tertiary referral hospital in Teresina, Piauí, Brazil. METHODS: A transversal and prospective study was conducted between September 2012 and February 2013. The cases were included according to criteria established by the WHO. Odds ratio, their respective confidence intervals, and multivariate analyses were examined. RESULTS: Five thousand eight hundred forty one live births, 343 women with SMM, 56 cases of MNM, and 10 maternal deaths were investigated. The rate for severe maternal outcomes was 11.2 cases per 1000 live births, the rate of MNM was 9.6 cases/1000 live births, and the rate for mortality was 171.2 cases/100,000 live births. Management criteria were most frequently observed among MNM/death cases. Hypertensive diseases (86.1%) and hemorrhagic complications (10.0%) were the main determinants of MNM, but infectious abortion was the most common isolated cause of maternal death. There was a correlation between MNM/death and hospitalized more than 5 days (p = 0.023) and between termination of pregnancy by cesarean (p = 0.002) and APGAR < 7 in the 1(st) minute (p = 0.015). CONCLUSIONS: SMM and MNM were quite prevalent in the population studied. Women whose condition progressed to MNM/death had a higher association with terminating pregnancy by cesarean, longer hospitalization times, and worse perinatal results. The results from the study can be useful to improve the quality of obstetric care and consequently diminish maternal mortality in the region.

Insights into potential pathogenesis mechanisms associated with Campylobacter jejuni-induced abortion in ewes.

BACKGROUND: Campylobacter jejuni is commonly found in the gastrointestinal tract of many food-animals including sheep without causing visible clinical symptoms of disease. However, C. jejuni has been implicated in ovine abortion cases worldwide. Specifically, in the USA, the C. jejuni sheep abortion (SA) clone has been increasingly associated with sheep abortion. In vivo studies in sheep (the natural host) are needed to better characterize the virulence potential and pathogenesis of this clone. RESULTS: Pregnant ewes intravenously (IV) or orally inoculated with ovine or bovine abortion-associated C. jejuni SA clones exhibited partial or complete uterine prolapse with retained placenta, and abortion or stillbirth, whereas delivery of healthy lambs occurred in pregnant ewes inoculated with C. jejuni 81-176 or in the uninfected group. In sheep inoculated with the SA clone, histopathological lesions including suppurative necrotizing placentitis and/or endometritis coincided with: 1) increased apoptotic death of trophoblasts, 2) increased expression of the host genes (e.g. genes encoding interleukin IL-6 and IL-15) related to cellular necrosis and pro-inflammatory responses in uterus, and 3) decreased expression of the genes encoding GATA binding protein 6, chordin, and insulin-like 3 (INSL3) that account for embryonic development in uterus. Immunohistochemistry revealed localization of bacterial antigens in trophoblasts lining the chorioallantoic membrane of ewes inoculated with the C. jejuni SA clone. CONCLUSIONS: The results showed that C. jejuni SA clones are capable of causing abortion or stillbirth in experimentally infected sheep. Furthermore, down- or up-regulation of specific genes in the uterus of infected pregnant ewes might implicate host genes in facilitating the disease progression. Since the C. jejuni SA strains share genotypic similarities with clones that have been isolated from human clinical cases of gastroenteritis, these strains might represent a potential public health risk.

Expression of toll-like receptors 2 and 4 in subplacental trophoblasts from guinea pigs (Cavia porcellus) following infection with Campylobacter jejuni.

Toll-like receptors 2 and 4 (TLR2 and TLR4) are well-characterized cell surface receptors that recognize specific pathogen-associated molecular patterns and play an important role in pathogen recognition and activation of the innate immune system. Variable expression of TLR2 and TLR4 has been described in trophoblasts from normal and diseased placentas; yet, there are limited data regarding trophoblast TLR expression in response to specific placental pathogens, and TLR expression in the guinea pig placenta has not been described. The guinea pig is an effective model for Campylobacter-induced abortion of small ruminants, and the authors have shown by immunohistochemistry that C jejuni localizes within syncytiotrophoblasts of the guinea pig subplacenta. The present study was designed to determine if the expression of either TLR2 or TLR4 would be affected in subplacental trophoblasts following infection with C jejuni. Immunohistochemistry for TLR2 and TLR4 was performed on placenta from guinea pigs that aborted following inoculation with C jejuni and from sham-inoculated controls. Quantitative assessment of TLR expression was performed, and mean immunoreactivity for TLR2 was significantly higher in subplacental trophoblasts from animals that aborted compared with uninfected controls (P = .0283), whereas TLR4 expression was not statistically different (P = .5909). These results suggest that abortion in guinea pigs following infection with C jejuni is associated with increased TLR2 expression in subplacental trophoblasts and may reveal a possible role for TLR2 in the pathogenesis of Campylobacter-induced abortion.

[Ovarian vein thrombosis. Risk factors, diagnosis and treatment]. / Trombosis de la vena ovárica. Factores de riesgo, diagnóstico y tratamiento.

Ovarian vein thrombosis is an uncommon complication (0.002-0.05%) related to hypercoagulated status of women. The most frequent condition associated to ovarian vein thrombosis is pregnancy, but there are other possible causes. We present a case of a 31 year old pregnant woman at 16th week of gestation who had spontaneuos septic abortion complicated with an ovarian vein thrombosis. A discussion of risk factors, diagnostic and treatment options of ovarian vein thrombosis are presented.

Acute cortical necrosis in pregnancy still an important cause for end-stage renal disease in developing countries.

Renal cortical necrosis (RCN) is a serious complication of acute kidney injury (AKI) and pregnancy is a clinical state closely associated with it with poor renal outcomes. The incidence is much higher in obstetrical AKI compared to other causes of RCN. Despite better medical care facilities available, this continues to be an important cause of morbidity and mortality in developing countries. This is a retrospective analysis among all pregnant females presenting with AKI from January 1999 to December 2014 at a tertiary care center in the northern part of India. We looked for the incidence of obstetrical-related RCN in our renal biopsies performed in the last 15 years and to evaluate precipitating factors responsible for RCN. RCN constituted 8.3% of pregnancy-related AKI cases in our institution. The overall incidence has been declining which was 9.09% from 1999 to 2008 to 7.8% from 2009 to 2014. The patient's median age was 29.3 ± 5.2 years. The average time to presentation from the day of delivery was 8.7 ±2.1 days. The mortality was observed in 11.7% of them with sepsis and multiorgan dysfunction present in all of them. The most common etiology for RCN was found to be septic abortion and puerperal sepsis accounting for - 15.3% each. Postpartum hemorrhage was a cause in 9.09% of patients. The most important cause of RCN was postpartum thrombotic microangiopathy which was observed in 48.7% of patients. Kidney biopsy was helpful in diagnosis in 31 patients while computed tomography scan abdomen alone helped in diagnosis in five patients. Patchy cortical necrosis in histology was seen in 35.4% of patients and morbidity in terms of prolonged hospitalization was seen in 22.7% while dialysis dependency in 61.5% of the study population. In conclusion, strategies need to be implemented in reducing the preventable causes for RCN which is not only catastrophic in terms of renal outcomes but also for social and psychological perspectives as well.

Prevalence of induced abortion and associated complications in women attending hospitals in Isfahan.

A high proportion of maternal deaths are caused by abortion, especially induced abortion. This cross-sectional study determined the prevalence of illegally-induced abortion prior to admittance and its associated risk factors in 8 maternity hospitals in Isfahan, Islamic Republic of Iran, during 2003-04. In confidential interviews with 417 women who attended the hospitals with abortion, 50 (12.0%) reported that it was illegally induced. These abortions had a significant correlation with fever, septic shock and septic abortion. Of all pregnancies, 35.0% were unwanted, and 27.1% of these were illegally-terminated by induced abortions. Unwanted pregnancy was one of the most important risk factors for induced abortion (OR = 8.84, 95% CI: 4.36-17.92).

Factors influencing post abortion outcomes among high-risk patients in Zimbabwe.

Post abortion complications remain one of the major causes of mortality among women of child bearing age in Zimbabwe. Based on this problem, factors associated with mortalities due to abortion were investigated with the aim of improving post abortion outcomes for Zimbabwe's women, and possibly also for women of other African countries. Cases and controls were selected from 4895 post abortion records to conduct a retrospective case-control study. Significant risk factors identified for reducing mortalities due to post abortion complications included the administration of oxytocic drugs and evacuation of the uterus whilst anaemia and sepsis apparently reduced these women's chances of survival. Women who died (cases) from post abortion complications apparently received better reported quantitative care than controls. Recommendations based on this research report include improved education of health care workers and enhanced in-service training, regular audits of patients' records and changed policies for managing these conditions more effectively in Zimbabwe.

Septic abortion with placenta accreta in pregnancy after endometrial ablation.

BACKGROUND: Pregnancy after endometrial ablation is a rare event, occurring in approximately 0.7% of cases. When it occurs, serious complications may be anticipated for both mother and fetus, including abnormal placentation. Termination of pregnancy in these cases is a challenging issue, made more so by the lack of availability of these services. CASE: We report a case of pregnancy after endometrial ablation complicated by placenta accreta. Initiation of a second-trimester termination procedure with lethal fetal injection resulted in subsequent septic abortion necessitating abdominal hysterectomy. CONCLUSION: Pregnancy after endometrial ablation is a rare and potentially morbid event. Patients should be counseled about the necessity of contraception at the time of endometrial ablation. Termination should be approached with caution and requires the availability of skilled providers.

Role of Campylobacter jejuni as a placental pathogen.

Members of the genus Campylobacter are well recognised as enteric pathogens but have rarely been implicated as human placental pathogens. A case of septic abortion due to C jejuni is reported. This occurred in a previously healthy woman with a diarrhoeal illness. The presence of chorioamnionitis raises the possibility of ascending infection rather than septicaemic spread as the pathogenesis. Members of the genus Campylobacter have special culture requirements and their incidence as placental pathogens may therefore be underestimated.

Medical abortion complications. An epidemiologic study at a mid-Missouri clinic.

PIP: A study of 420 cases of vacuum aspiration abortions in a central Missouri family planning clinic found 33 postabortal complications, 14 of which occurred over 10 weeks; 12 under 7. Most patients were white nulliparous females under 30. 41.5% of complications were incomplete abortions, only one of which occurred between 7 1/2-9 1/2 weeks, 4 times more at less than 7 weeks, 11 times more for women over 10 weeks. 25% were cervical lacerations, which occurred less frequently at advanced stages of gestation, 21.2% were postabortal hemorrhage, occurring most frequently over 10 weeks. The optimum time for less risk of postabortal complications is 7 1/2-9 1/2 weeks gestation. 18% complications, 7% incomplete abortions occurred at 7 1/2-9 1/2 weeks. During early pregnancy the progesterone block influences uterine motility and may be a survival mechanism for the fetus. The corpus luteum of pregnancy secretes large amounts of progesterone for the first 60 days and lesser quantities for the next 30 days.^ieng

Fatal septic abortion in the United States, 1975-1977.

In 1975 through 1977, 36 women in the United States died of septic abortion (12 legal, 15 spontaneous, 8 illegal, and 1 unclassified). The respective estimated death-to-case rates for septic abortion are 0.4 and 0.6 deaths per 100,000 legal and spontaneous abortions. Unmarried teenagers who undergo incomplete abortion at 16 weeks' gestation or more by intrauterine placement of a foreign body appear to have the highest risk of death from infection after legal abortion. Three of these risk factors (gestational age at the time of abortion, method, and completeness of abortion) can be influenced by medical personnel. Complete abortion by safe techniques early in pregnancy can help eliminate deaths from infection after legal abortion.

Ovine chlamydiosis in an abattoir worker.

The strain of Chlamydia psittaci causing enzootic abortion in ewes (the EAE strain) may cause serious infection in pregnant women, often resulting in hepatic and renal dysfunction, disseminated intravascular coagulation and fetal loss. The first case of such an infection in an abattoir worker is described and the possibility of human-to-human transmission considered. Direct handling of sheep or their products of conception can usually be established but this is not always so. There is much still to be learned about this uncommon but severe zoonosis.

Identification of Ehrlichia risticii as the causative agent of two equine abortions following natural maternal infection.

Two pregnant mares diagnosed as having equine monocytic ehrlichiosis based on history, clinical signs, and high serum antibody titers to Ehrlichia risticii aborted subsequent to recovery from illness. Mare 1 and mare 2 experienced clinical illness at 120 and 143 days of gestation and aborted at 203 and 226 days of gestation, respectively. The fetuses were expelled in fresh condition, and both mares retained their placentas upon abortion. Gross findings for the fetuses included meconium staining and petechiation of external surfaces. Internally, there was increased volume of feces within the small and large intestines and liver discoloration with enlargement. Microscopic findings included lymphohistiocytic enterocolitis, hepatitis, and myocarditis. Lymphoid hyperplasia and depletion were present in spleen, thymus, and lymph nodes. Ehrlichia risticii was recovered from bone marrow, spleen, lymph node, colon, and liver of the first fetus and bone marrow and colon of the second fetus. Electron microscopic evaluation of the organism isolated in cell culture revealed morphology consistent with E. risticii. The isolated organism was inoculated into a naive pony, and this pony developed high levels of antibody against E. risticii, became ehrlichemic, and developed clinical signs of depression, anorexia, and mild diarrhea. These findings confirm that E. risticii is an abortifacient under conditions of natural infection and should be considered as a differential diagnosis of equine abortions.

The benefits and risks of IUD use.

Next to combination oral contraceptives (OCs), intrauterine contraceptive devices (IUDs) are the most effect form of contraception available. IUDs require only one-time motivation, cause no systemic metabolic effects, and do not depend on continued action of the user for effectiveness. Risks, side effects and complications of this method, including expulsion, perforation pain, bleeding and infection, are reviewed.

Septic abortion at University College Hospital, Ibadan, Nigeria.

One hundred forty-three cases of septic abortion managed over 5 years are reviewed. Sepsis was more common after induced abortion often performed by non-gynecologists. Instrumentation was commonly performed in the homes, chemists and poorly equipped private clinics. Complications were generally severe and maternal mortality was 8.4%. Treatment was individualized but there was no standard antimicrobial regime.

Conservative vs. surgical management of septic abortion with renal failure.

The role of surgery in the management of postabortum renal failure complicated with extensive uterine sepsis, perforation or peritonitis is controversial. This study compares the course and final outcome of 14 patients (66.6%) conservatively managed with appropriate antibiotics, fluid or blood replacement and dialysis, with seven patients (33.3%) for whom hysterectomy or laparotomy was undertaken in addition. Whereas all 14 patients treated conservatively died as the result of uncontrolled septicemia, three of the seven surgical patients recovered completely. Extensive necrosis with perforation of the uterine wall was confirmed either at laparotomy or at autopsy in all 21 women. To reduce mortality, the authors recommend early surgical intervention for patients suffering from postabortum renal failure complicated with uterine sepsis or perforation.

Bowel injury in septic abortion: the need for more aggressive management.

An analysis of bowel injury in cases of septic abortion treated over a six-year period at the University of Nigeria Teaching Hospital at Enugu is presented. Seventy-three percent (11/15) of the patients who underwent laparotomy had concomitant injury to the bowels. Overall, 16.4% of the 67 patients with septic abortion had intestinal injuries (this does not include the patients who died as a result of fulminating peritonitis before surgery could be performed). The survival of those patients with intestinal injuries was very much dependent on the operative procedures adopted. When a dysfunctioning colostomy was raised, the mortality was nil. In patients who had simple closure of the perforation and in those who had primary resection and anastomosis, mortality was 66.6%. The importance of performing laparotomy much sooner than usual is discussed.

Intrauterine devices: medicated and nonmedicated.

The main benefits of intrauterine devices (IUDs) are a lack of adverse systemic effects, excellent effectiveness, high continuation rates and the single act of motivation required for use. First year failure rates range from 2% to 3%, but decline steadily thereafter to a cumulative annual failure rate of less than 1% after six years. The risks of IUDs include increased blood loss, uterine perforation, pelvic infection and pregnancy-related complications. The incidence of perforation of the uterine fundus ranges from 1:1000 to 1:2500 insertions, while that of cervical perforation with the copper devices ranges from 1:600 to 1:1000. IUD use is associated with about a three-fold increased incidence of developing acute salpingitis in comparison with use of oral contraceptives and diaphragms. If pregnancy occurs with an IUD in place, there is a three-fold increased risk of spontaneous abortion, a ten-fold increased risk of ectopic pregnancy (5% of all IUD pregnancies) and a possible increased incidence of sepsis during the pregnancy.