• About 10% of abortion requiring admission to hospital are septic
• The majority of septic abortion are associated with incomplete abortion

MODE OF INFECTION

1. Contaminated Instruments or Equipment: If the instruments used during the abortion procedure are not properly sterilized or if they come into contact with non-sterile surfaces or materials, they can introduce bacteria into the uterus. This can lead to infection, which may progress to sepsis if untreated.
2. Incomplete Abortion: If the abortion procedure is incomplete, meaning that not all of the products of conception (fetal tissue, placenta, etc.) are completely removed from the uterus, it can provide a breeding ground for bacteria. Retained products can lead to infection and subsequent sepsis if not promptly addressed.
3. Unsterile Conditions: Abortions performed in environments lacking proper sanitation and hygiene standards increase the risk of infection. This includes facilities where procedures are performed without adequate sterilization of equipment or where proper hand hygiene practices are not followed by healthcare providers.
4. Infection from Vaginal Microbiota: Normally, the vagina harbors a complex microbiota that includes both beneficial and potentially harmful bacteria. During an abortion procedure, particularly if the cervix is dilated, there is a risk that bacteria from the vaginal microbiota can ascend into the uterus, leading to infection.
5. Post-procedural Care: Inadequate post-procedural care, including failure to administer prophylactic antibiotics or failure to monitor for signs of infection, can contribute to the development of septic abortion.
6. Pre-existing Infections: Rarely, a pre-existing infection in the reproductive tract (such as pelvic inflammatory disease) can predispose a woman to developing sepsis following an abortion procedure.

BACTERIA THAT AFFECT IN SEPTIC ABORTION :

1. Escherichia coli (E. coli): E. coli is a Gram-negative bacterium that is a frequent cause of infections following septic abortion. It is part of the normal intestinal flora but can cause serious infections if it enters the uterus during or after an abortion procedure.
2. Enterococcus species: Enterococcus faecalis and Enterococcus faecium are Gram-positive bacteria that are part of the normal flora of the gastrointestinal tract and female genital tract. They can cause infections if they contaminate the uterine cavity during abortion procedures.
3. Streptococcus species: Several species of Streptococcus can cause infections, including Group A streptococcus (Streptococcus pyogenes) and Group B streptococcus (Streptococcus agalactiae). These bacteria can lead to serious infections if they enter the uterus and cause sepsis.
4. Clostridium species: Certain species of Clostridium, such as Clostridium perfringens, are anaerobic bacteria that can cause gas gangrene and severe infection if they contaminate the uterine cavity during abortion procedures.
5. Staphylococcus aureus: Staphylococcus aureus is a Gram-positive bacterium that can cause infections if it enters the uterine cavity. It is known for its ability to produce toxins that can lead to toxic shock syndrome in severe cases.
6. Bacteroides species: Bacteroides fragilis and other Bacteroides species are anaerobic bacteria that can cause infections, particularly in cases of septic abortion where there is contamination of the uterine cavity with fecal material.

CLINICAL FEATURE :

• The women looks sick and anxious
• temperature :>38 degree C
• Chills and rigor
• Persistent tachycardia
• Hypothermia
• Abdominal or chest pain
• Tachypnea (RR) >20/MIN
• Impaired mental state
• Diarrhea
• vomiting
• Renal angle tenderness
• Vaginal discharge
• Uterine tenderness
• Pelvic abscess

COMPLICATION :

1. Sepsis: This is a systemic inflammatory response to infection that can lead to organ dysfunction. It is characterized by fever, elevated heart rate, respiratory distress, and altered mental status. If not treated promptly, sepsis can progress to severe sepsis and septic shock.
2. Disseminated Intravascular Coagulation (DIC): In severe cases of septic abortion, the body’s response to infection can lead to widespread activation of the clotting cascade, causing both clotting and bleeding problems. DIC can lead to multi-organ failure and is associated with a high mortality rate.
3. Pelvic Abscess: Infections can lead to the formation of abscesses within the pelvic cavity, which may require drainage and prolonged antibiotic therapy.
4. Peritonitis: If the infection spreads beyond the uterus and involves the abdominal cavity, peritonitis (inflammation of the peritoneum) can occur. This can lead to severe abdominal pain, distension, and signs of systemic illness.
5. Septic Shock: This is a life-threatening condition where severe infection leads to dangerously low blood pressure and inadequate blood flow to organs. Septic shock requires immediate intensive care management, including fluid resuscitation and administration of antibiotics.
6. Organ Failure: Prolonged sepsis and septic shock can lead to dysfunction or failure of multiple organs, such as the lungs (acute respiratory distress syndrome, ARDS), kidneys (acute kidney injury), liver, and heart.
7. Infertility: Severe pelvic infections from septic abortion can cause scarring and damage to the uterus, fallopian tubes, and ovaries, potentially leading to infertility or complications in future pregnancies.
8. Psychological Impact: Enduring a septic abortion and its complications can have significant psychological consequences for the patient, including anxiety, depression, and post-traumatic stress disorder (PTSD).

INVESTIGATION :

1. Clinical Assessment: This includes a thorough history-taking and physical examination to assess the patient’s symptoms, signs of infection (fever, abdominal pain, vaginal discharge, etc.), and signs of systemic involvement (e.g., hypotension, tachycardia).
2. Laboratory Investigations:
   • Complete Blood Count (CBC): This helps to assess for leukocytosis (elevated white blood cell count), which indicates an inflammatory response to infection. Neutrophilia (elevated neutrophil count) is often present in bacterial infections.
   • Blood Cultures: These are crucial to identify the causative bacteria and guide antibiotic therapy. Blood cultures should ideally be taken before starting antibiotics if possible.
   • Inflammatory Markers: Measurement of C-reactive protein (CRP) and procalcitonin levels can help assess the severity of the infection and response to treatment.
3. Imaging Studies:
   • Transvaginal Ultrasound: This may be used to assess the uterine cavity for retained products of conception (indicating incomplete abortion) and signs of infection such as fluid collections or abscess formation.
   • Abdominal Ultrasound or CT Scan: In cases of severe infection or suspected complications (such as pelvic abscess), these imaging modalities may be used to evaluate for intra-abdominal pathology.
4. Microbiological Studies:
   • Endometrial or Vaginal Swabs: These may be obtained for culture and sensitivity testing to identify the specific bacteria causing the infection, especially if the blood cultures are negative.
5. Other Investigations:
   • Coagulation Studies: In severe cases, assessment of coagulation parameters may be necessary to evaluate for disseminated intravascular coagulation (DIC), which can occur as a complication of septic abortion.
   • Renal Function Tests: These may be performed to assess renal function, especially if there is concern for septic shock and potential acute kidney injury.
6. Clinical Severity Assessment:
   • Sequential Organ Failure Assessment (SOFA) Score: This score may be used to assess the severity of organ dysfunction in cases of sepsis or septic shock.

MANAGEMENT OF SEPTIC ABORTION :

Here is an outline of the general principles and steps involved in managing septic abortion:

1. Stabilization and Initial Assessment

• Immediate Resuscitation: Start with basic life support measures including airway management, oxygen administration, and intravenous (IV) access.
• Fluid Resuscitation: Administer IV fluids to restore intravascular volume and improve perfusion.
• Monitoring: Continuously monitor vital signs including heart rate, blood pressure, respiratory rate, and oxygen saturation.

2. Diagnostic Workup

• Clinical Assessment: Perform a thorough clinical examination to assess the severity of symptoms and signs of sepsis.
• Laboratory Investigations:
  • Complete Blood Count (CBC): Assess for leukocytosis and other signs of infection.
  • Blood Cultures: Obtain cultures to identify the causative bacteria and guide antibiotic therapy.
  • Serum Chemistry: Check electrolytes, renal function tests, and liver function tests.
  • Coagulation Studies: Assess for signs of disseminated intravascular coagulation (DIC) if clinically indicated.
• Imaging Studies: Consider transvaginal ultrasound or abdominal imaging to assess for retained products of conception, pelvic abscesses, or other complications.

3. Medical Management

• Antibiotic Therapy: Initiate broad-spectrum antibiotics empirically based on local guidelines and culture results once available. Examples include:
  • Ampicillin plus gentamicin
  • Clindamycin plus gentamicin

  Adjust antibiotics based on culture and sensitivity results to ensure appropriate coverage.

• Supportive Care: Provide supportive measures including pain management, antiemetics if needed, and nutritional support.

4. Surgical Management

• Evacuation of Uterus: If there are retained products of conception identified on imaging or clinically, perform uterine evacuation. This can be done via dilation and curettage (D&C) or suction aspiration.
• Abscess Drainage: If pelvic abscesses are present and accessible, drainage may be necessary either by ultrasound-guided aspiration or surgical drainage.

5. Monitoring and Follow-up

• Intensive Care: Consider admission to intensive care unit (ICU) for close monitoring of critically ill patients, especially those with septic shock or multi-organ dysfunction.
• Serial Assessments: Monitor clinical status, vital signs, laboratory parameters, and response to treatment closely.

6. Complications Management

• Management of Sepsis and Septic Shock: Implement protocols for sepsis management including early goal-directed therapy, vasopressor support if needed, and consideration of renal replacement therapy for acute kidney injury.
• Management of DIC: Treat underlying infection, replace clotting factors and platelets as needed, and address any bleeding complications.

7. Psychosocial Support

• Counseling and Support: Offer psychological support to the patient and her family due to the emotional distress associated with septic abortion and its management.

8. Prevention of Future Infections

• Education: Provide education on contraception and safe abortion practices to prevent future unplanned pregnancies and reduce the risk of unsafe abortions.

9. Follow-up Care

• Post-treatment Monitoring: Arrange for appropriate follow-up to monitor resolution of infection, assess for complications, and provide contraception counseling.

PREVENTION OF SEPTIC ABORTION:

 Here are key strategies for preventing septic abortion:

1. Access to Safe Abortion Services

• Legalization and Accessibility: Ensure that safe and legal abortion services are available and accessible to all women who need them. Legalizing abortion helps reduce the incidence of unsafe procedures performed under unhygienic conditions.
• Training of Healthcare Providers: Train healthcare providers in safe abortion techniques, including use of appropriate equipment, sterilization procedures, and post-abortion care.
• Quality Assurance: Implement quality assurance programs to ensure that abortion services meet established medical standards and guidelines.

2. Contraception and Family Planning

• Access to Contraception: Increase access to a wide range of contraceptive methods to prevent unintended pregnancies. Effective contraception reduces the need for unsafe abortions.
• Comprehensive Counseling: Provide comprehensive counseling on contraceptive options, including their effectiveness, benefits, and side effects.

3. Education and Awareness

• Sexual and Reproductive Health Education: Implement educational programs on sexual and reproductive health in schools, communities, and healthcare settings. This includes information on contraception, safe sex practices, and the consequences of unsafe abortions.
• Awareness of Signs and Symptoms: Educate women on recognizing signs and symptoms of pregnancy and seeking timely medical care if they suspect they are pregnant or have complications.

4. Improving Socioeconomic Conditions

• Poverty Alleviation: Address socio-economic factors that contribute to unsafe abortions, such as poverty and lack of access to healthcare services.
• Empowerment of Women: Promote women’s empowerment through education, economic opportunities, and access to healthcare, which can help reduce unintended pregnancies and unsafe abortions.

5. Regulation and Policy

• Regulatory Framework: Establish and enforce laws and policies that protect women’s reproductive rights and ensure access to safe abortion services.
• Monitoring and Evaluation: Regularly monitor and evaluate the implementation of policies related to reproductive health and abortion services to ensure effectiveness and quality.

6. Community Engagement

• Community-Based Programs: Engage communities in discussions about reproductive health, contraception, and safe abortion practices. This helps reduce stigma associated with abortion and encourages supportive environments for women seeking reproductive healthcare.

7. Emergency Obstetric Care

• Availability of Emergency Services: Ensure access to emergency obstetric care for managing complications of unsafe abortions, including septic abortion. This includes facilities equipped to manage sepsis and provide surgical interventions if needed.

8. Post-Abortion Care

• Comprehensive Post-Abortion Care: Provide accessible and comprehensive post-abortion care, including counseling, contraceptive services, and treatment of complications to prevent future infections or unintended pregnancies.