Septic abortion: Clinical presentation and management

TopicGraphics (6)

AUTHORS:Sarah Prager, MD, MASElizabeth Micks, MD,

MPHVanessa K Dalton, MD, MPHSECTION EDITORS:Robert L
Barbieri, MDCourtney A Schreiber, MD, MPHLiina Poder, MDDEPUTY
EDITOR:Kristen Eckler, MD, FACOG

Contributor Disclosures

All topics are updated as new evidence becomes available and our peer review process is
complete.

Literature review current through: Sep 2023.

This topic last updated: Jul 18, 2023.

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'.)

(See "Second-trimester pregnancy termination: Dilation and

evacuation", section on 'Prophylactic antibiotics'.)

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 "Sepsis syndromes in adults: Epidemiology, definitions,

clinical presentation, diagnosis, and prognosis", section on
'Clinical presentation'.)

(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 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".)

(See "Sepsis syndromes in adults: Epidemiology, definitions,

clinical presentation, diagnosis, and prognosis", section on
'Definitions'.)

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.

(See "Acute appendicitis in adults: Clinical manifestations

and differential diagnosis", section on 'Computed
tomography findings'.)

(See "Clinical manifestations and diagnosis of acute colonic

diverticulitis in adults", section on 'Computed tomography
scan'.)

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 females".)

(See "Acute complicated urinary tract infection (including

pyelonephritis) in adults".)

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.

(See "Evaluation and management of suspected sepsis and

septic shock in adults", section on 'Initial resuscitative therapy'.)

(See "Initial management of moderate to severe hemorrhage in

the adult trauma patient", section on 'Resuscitation and
transfusion'.)

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 "Sepsis syndromes in adults: Epidemiology, definitions,

clinical presentation, diagnosis, and prognosis", section on
'Clinical presentation'.)

(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.

-
 (See "Evaluation and management of suspected sepsis
and septic shock in adults", section on 'Immediate
evaluation and management'.)

(See "Initial management of moderate to severe

hemorrhage in the adult trauma patient", section on
'Resuscitation and transfusion'.)

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.

Use of UpToDate is subject to the Terms of Use.

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