S.Y.

Lin, et al ■ SHORT COMMUNICATION ■

SEPTIC SHOCK AFTER INTRACERVICAL

LAMINARIA INSERTION
1
Shin-Yu Lin, Wen-Fang Cheng, Yi-Ning Su , Chi-An Chen, Chien-Nan Lee*
Departments of Obstetrics and Gynecology and 1Medical Genetics,
National Taiwan University Hospital, Taipei, Taiwan.

SUMMARY
Objective: Laminaria placement is seldom thought to be associated with postabortal sepsis.
Case Report: A nulliparous woman presented with high fever, low blood pressure, and signs of infection during
artificial legal abortion with laminaria placement for cervical dilatation. Broad-spectrum antibiotics were given.
Cultures of blood, placenta, and arterial line all yielded Enterobacter cloacae. The patient responded to antibiotics
and supportive care.
Conclusion: The use of laminaria still places patients at risk for infection because there is a certain risk of
ascending colonization with potentially pathogenic microorganisms from the vaginal and cervical microflora,
as in our patient. Surgical disinfection, prophylactic antibiotics, and shortened duration of laminaria placement
are helpful to prevent infectious insult. Once signs of infection are noted, physicians should take action as
soon as possible, such as initiating broad-spectrum antibiotics and intensive care. [Taiwanese J Obstet Gynecol
2006;45(1):76–78]

Key Words: laminaria, septic abortion, termination

Introduction the first report of sepsis due to E. cloacae bacteremia

There are many ways to facilitate mid-trimester abor-
tion, including osmotic cervical dilatation with lamina-
ria japonicum tents, prostaglandin E2 vaginal tablets,
and sulprostone intravenous infusion. Osmotic cervical
dilatation is considered safe and effective. We have
used it uneventfully in more than 800 patients in
the past 10 years. Despite the inability to sterilize the
laminaria, it is seldom associated with infection [1].
We present the case of a patient who used laminaria for
cervical dilatation and suffered sepsis and severe bac-
teremia. MEDLINE and PUBMED searches using the
words “laminaria”, “sepsis”, and “Enterobacter cloacae”
from 1966 to December 2004 suggest that this is
*Correspondence to: Dr. Chien-Nan Lee, Department of Obstetrics
and Gynecology, National Taiwan University Hospital, 7 Chung-
Shan South Road, Taipei, Taiwan.
E-mail: leecn@ha.mc.ntu.edu.tw
Received: October 4, 2005
Revised: October 6, 2005
Accepted: October 12, 2005
associated with laminaria for elective abortion.
Case Report
A nulliparous 32-year-old woman at 17 weeks’ gesta-
tion was admitted for elective abortion due to fetal om-
phalocele. She had four laminaria placed after betadine
vaginal disinfection. A purulent whitish vaginal dis-
charged was noted. The patient took oral prophylactic
cephalexin one capsule 250 mg every 6 hours. The
next morning, sulprostone was given intravenously
to augment uterine contractions. The laminaria was
uneventfully removed 22 hours later. After artificial
rupture of the membranes on the 3rd morning, no
malodor or dirty amniotic fluid was noted. A three-way
Foley catheter with 50 mL of distilled water was inserted
into the cervix to facilitate cervical dilatation. However,
chills and fever up to 39.9° C developed 2 hours later.
We stopped sulprostone immediately because it is
reported to cause a febrile reaction. We also added
cefamezine 1.0 g intravenously every 8 hours as

76 Taiwanese J Obstet Gynecol • March 2006 • Vol 45 • No 1


prophylaxis. Two sets of blood cultures were performed
immediately. A dead fetus was expulsed 5 hours later.
Tachycardia (144 bpm) and low blood pressure
(75/42 mmHg) were noted after abortus delivery. The
body temperature was up to 38.8° C and oxygen
saturation was 96% under room air. The patient’s con-
sciousness was clear throughout the whole course.
Leukopenia (from 6,890 to 1,600 × 103/μL) was noted
and, under the impression of sepsis, she was transferred
to the intensive care unit. Empiric antibiotic treatment
included ampicillin/sulbactam, gentamicin, and met-
ronidazole. Ampicillin/sulbactam was replaced with
intravenous ceftazidime to cover pseudomonas
infection. Thrombocytopenia (from 245 to 91 × 103)
and positive disseminated intravascular coagulation
profiles were noted, and packed red blood cells (500
mL) and fresh frozen plasma (4 U) were supplied.
3
Leukocytosis (from 1,600 to 7,220 to 11,680 × 10 /μL)
and elevating C-reactive protein (from 2.87 to 18.47
mg/dL) developed 1 day later.
Two sets of peripheral blood cultures, one set of
arterial line blood cultures, and a placental culture all
yielded E. cloacae within 24 hours. From the sensitivity
results, we switched ceftazidime to ceftriaxone and
stopped metronidazole. The fever subsided and the
patient did well, with blood pressure stabilizing to
90–120/58–70 mmHg. Antibiotics were continued
for the full 10-day course at the infection specialist’s
suggestion. The patient was discharged in a stable con-
dition and no oral antibiotics were prescribed.
Discussion
The hydroscopic property of laminaria enables it to
expand up to five times in diameter over 12–24 hours,
thereby gradually dilating the cervix. It has been further
hypothesized that this gradual mechanical stretching
provides a stimulus for the local release of the pro-
staglandin, cytokines, and elastase thought to be im-
portant in cervix ripening [2]. Laminaria tents fell out of
favor in the early 20th century because of complications
due to infection. The potential for these sea plants to
harbor pathogens led some investigators to speculate
that colonization of laminaria tents may lead to post-
abortive infection. Recently, with modern sterilization
techniques using ethylene oxide and -irradiation, la-
minaria tents are re-emerging as an option for cervical
dilatation. The associated infection rates are similar to
those achieved with standard methods.
Evaldson et al sent endocervical specimens for cul-
ture preoperatively and laminaria postoperatively in 53
women who requested first-trimester abortion [3]. No
Taiwanese J Obstet Gynecol • March 2006 • Vol 45 • No 1
Septic Shock after Laminaria Insertion
clinically verified endometritis/salpingitis was registered
in this study and the authors concluded that presurgi-
cal dilatation with laminaria tents involves a negligible
risk of a pelvic inflammatory disease as long as the
treatment does not exceed 24 hours. In a clinical series
of 1,000 consecutive dilation and evacuation (D&E)
abortions at 17–26 weeks’ gestation using multiple
laminaria treatments over 48 hours, Hern reported the
following complications possibly attributable in part
to laminaria use: three minor intraoperative cervical
lacerations and one infection before D&E [4]. Bryman
et al compared laminaria tents with Hegar dilators
and reported a 2% incidence of endometritis in
the laminaria group versus 13% in the Hegar dilator
group [5]. Similarly, a prospective randomized study
involving 519 women revealed that the rate of post-
abortal inflammatory disease was significantly lower
after pretreatment with laminaria tents [6].
Septic abortions are usually polymicrobial, with
bacteria derived from the normal flora of the vagina
and endocervix, and the important addition of sexually
transmitted pathogens. The Gram-positive aerobic cocci
Staphylococcus epidemidis, Streptococcus faecalis, and Strep-
tococcus agalactiae as well as Escherichia coli and Klebsiella/
Enterobacter are the most frequent microorganisms
among aerobic isolates from endocervices and laminaria
tents [3]. Our patient had bacteremia with E. cloacae
following placement of laminaria. E. cloacae is a Gram-
negative bacillus that is more commonly a cause of
hospital-acquired infection in immunocompromised
patients and is not susceptible to -lactam antibiotics.
It has been associated with a major epidemic of intraven-
ous line contamination. However, we followed appro-
priate aseptic technique between patients and there
was no horizontal spread in our hospital. Our Infection
Control Committee failed to find an association between
this patient’s bacteremia and intravenous line contami-
nation. It is fortunate that these bacteria responded to
our empiric ceftazidime and gentamicin. We suggest
the use of broad-spectrum antibiotics as soon as possible
in cases of suspected septic abortion.
Although the infection rate associated with laminaria
has decreased with improving sterilization techniques,
the use of laminaria still places patients at some risk
for infection. There is a certain risk of ascending coloni-
zation with potentially pathogenic microorganisms
from the vaginal and cervical microflora, as occurred in
our patient. Therefore, presurgical vaginal preparation,
aseptic techniques, short duration of laminaria place-
ment, and prophylactic antibiotics play a role. Once
patients present with signs of infection, the clinician
should be alert for septic abortion and use broad-
spectrum antibiotics empirically.
77
S.Y. Lin, et al
References
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