Grand Rounds

Woman, 36, With Fever and Malaise

Clinician Reviews. 2016 September;26(9):30-33

References

1. Promislow JH, Baird DD, Wilcox AJ, et al. Bleeding following pregnancy loss prior to six weeks gestation. Hum Reprod. 2007;22(3):853-857.
2. Ramoska EA, Sacchetti AD, Nepp M. Reliability of patient history in determining the possibility of pregnancy. Ann Emerg Med. 1989;18(1):48-50.
3. Osazuwa H, Aziken M. Septic abortion: a review of social and demographic characteristics. Arch Gynecol Obstet. 2007;275(2):117-119.
4. Hure AJ, Powers JR, Mishra GD, et al. Miscarriage, preterm delivery, and stillbirth: large variations in rates within a cohort of Australian women. PLoS One. 2012;7(5):e37109.
5. Nielsen S, Hahlin M. Expectant management of first-trimester spontaneous abortion. Lancet. 1995;345(8942):84-86.
6. Eschenbach DA. Treating spontaneous and induced septic abortions. Obstet Gynecol. 2015;125(5):1042-1048.
7. Rana A, Pradhan N, Gurung G, Singh M. Induced septic abortion: a major factor in maternal mortality and morbidity. J Obstet Gynaecol Res. 2004;30(1):3-8.
8. Abbasi S, Jamal A, Eslamian L, Marsousi V. Role of clinical and ultrasound findings in the diagnosis of retained products of conception. Ultrasound Obstet Gynecol. 2008;32(5):704-707.
9. Esmaeillou H, Jamal A, Eslamian L, et al. Accurate detection of retained products of conception after first- and second-trimester abortion by color doppler sonography. J Med Ultrasound. 2015;23(7):34-38.
10. Finkielman JD, De Feo FD, Heller PG, Afessa B. The clinical course of patients with septic abortion admitted to an intensive care unit. Intensive Care Med. 2004;30(6):1097-1102.
11. CDC. Sexually transmitted diseases treatment guidelines, 2010. MMWR Recomm Rep. 2010;59(RR-12):1-110.
12. Mackeen AD, Packard RE, Ota E, Speer L. Antibiotic regimens for postpartum endometritis. Cochrane Database Syst Rev. 2015;2:CD001067.

Treatment and prognosisPatients with a septic abortion require immediate evacuation of the uterus to prevent deadly complications; antibiotics may not be able to perfuse to the necrotic source of infection.¹⁰ Suction curettage is less likely than sharp curettage to cause perforation.

Broad-spectrum antibiotics should be administered. The bacteria associated with a septic incomplete miscarriage are usually polymicrobial and represent the normal flora of the vagina and cervix. The choice of agents recommended is usually the same as for pelvic inflammatory disease.¹¹

The treatment regimen typically includes clindamycin (900 mg IV q8h), plus gentamicin (5 mg/kg IV once a day), with or without ampicillin (2 g IV q4h).^11,12 Alternatively, a combination of ampicillin, gentamicin, and metronidazole (500 mg IV q8h) can be used.

Further surgery, including laparotomy and possible hysterectomy, is indicated in patients who do not respond to uterine evacuation and parenteral antibiotics. Other possible complications requiring surgery include pelvic abscess, necrotizing Clostridium infections in the myometrium, and uterine perforation.

OUTCOME FOR THE CASE PATIENTThe patient was started on IV ampicillin, gentamicin, and clindamycin and taken promptly for a suction dilation and curettage. Pathology later showed a gestational sac with severe acute necrotizing chorioamnionitis and extensive bacterial growth. This confirmed the diagnosis of a septic, incomplete miscarriage.

Blood cultures remained without any growth, and the patient was afebrile on the second postop day. The WBC count and β-hCG level trended downward.

The patient was discharged on a 14-day course of oral doxycycline and metronidazole. She was then lost to further follow-up.

CONCLUSIONThe differential diagnosis in this ill, febrile patient was initially very broad. The importance of suspecting pregnancy in all women of childbearing age, especially those not using contraception, cannot be underestimated. The accuracy of patient history and recall of last menstrual period in determining the possibility of pregnancy is not sufficiently reliable.

Woman, 36, With Fever and Malaise

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