Abortion Complicated By Infection
Bacteriology : All manner of organisms, especially saprophytes, are normally presents in the uterus and vagina during and after abortion; they play a physiological scavenger role. Even Clostridium welchii is commonly found. The growth of particular bacteria from the vagina and cervix is not necessarily of any significance and has to be interpreted in relation to clinical features.
1. Bacillus coil
2. Non-haemolytic streptococcus
3. Anaerobic streptococcus
4. Staphylococcus aureus
5. Haemolytic streptococcus
6. Cl. welchii
9. Tetanus bacillus
Mode of Entry
Although blood stream spread from another site in the body is a theoretical possibility the organisms nearly always reach the vulva, vagina and uterus by way of one of the following methods.
1. Droplet infection from the upper respiratory tract of attendants.
2. The hands and instruments of attendants. Lack of care in this respect explains why the most serious infections commonly follow criminal follow criminal abortion. Some say that a septic abortion is always a criminal abortion but this is an overstatement. Infection commonly complicates spontaneous abortion.
3. The patient’s own hands which may transfer organisms from the nose, month and anus.
4. Atmospheric dust.
5. Bed linen, dressings and utensils such as bed pans.
6. Direct or indirect contact with another individual patient, friend or relative, suffering from any sort of infection in any site.
In 40 percent cases of septic abortion, the infection is limited to the products of conception themselves, and there is no invasion of maternal tissues. In the others the placental site and endometrium (decidua) become involved in endometritis which is either localized or spreading.
Localized endometritis 40%
This wss called putrid endometritis in the past, and the organisms involved are usually endogenous and of low virulence- anaerobic streptococci, coliform bacilli and and staphylococci. The infection is kept to the superficial layers of the endometrium by a sharp protective response on the part of the underlying tissues which lay down a ‘barrier of leucocytes’.
Spreading endometritis 60%
This was formerly called septic endometritis. This infecting agent is more virulent, often the exogenous haemolytic streptococcus, and local reaction and resistance are slight. The whole depth of the endometrium, and sometimes the myometrium, are involved. Occasionally the uterus becomes gangrenous. The organisms spread by lymph and blood channels to produce general peritonitis or septicaemia. Infections of intermediate severty cause salpingo-oophoritis, pelvic peritonitis, pelvic cellulitis and suppurative thrombophlebitis with pyaemia, all of which are described.
This is the most obvious and usually the first sign. It does not necessarily mean that the infection has spread beyond the products of conceptions and often disappears as soon as abortion is complete. It may be caused only by degenerating blood clot. The severity of the infection is not always proportional to the height of the temperature and a low temperature can have serious portent. Rigors usually denote blood stream spread.
A rise in pulse rate is a important sign than pyrexia. If the rate is more than 110 per minute it usually means that the infection is spreading beyond the uterus.
The time at which pyrexia and tachycardia occur in relation to spontaneous or surgically completed abortion is helpful is diagnisis. Spreading endometritis and septicaemia manifest themselves within 48 hours, often within 24 hours; pelvic peritonitis on the second or third day; localized endometritis on the third or fourth day; cellulitis and septic thrombophlebitis on the tenth day.
An offensive, sometimes frankly purulent, uterine discharge is a feauture of localized infections, hence the old term ‘putrid’ endometritis. It can be vary foul, and forthy, when Cl. welchii organisms are present. In the more serious infections, for example septicaemia, the uterus is often empty and the lochial discharge scanty.
Tenderness of the uterus
This is not significant unless the abortion is complete.
There is usually a moderate degree of leucocytosis associated with all abortions. The number of polymorphonuclear leucocytes has to be grossly increased, or associated with toxic granulation of the white cell’s cytoplasm, for the finding to indicate serious infection.
Although pelvic peritonitis can cause lower abdominal pain, general peritonitis is often unaccompanied by pain, tenderness and rigidity. This condition in the puerperium is manifested mainly by distension and vomiting.
General systemic upset
This varies with the severity of the infection and includes anorexia, vomiting, joint pains, headache, flushed appearance, sweating, dehydration and ultimately mental disorientation and coma. Rapid destruction of blood cells to cause profound anaemia is a feature of septicaemia, especially if the haemolytic streptococcus or Cl. welchii is involved.
Infection with Cl. welchii results in a systemic upset characterized by the rapid onset of severe prostration, accompained by hypotension and tachycardia. The temperature may be high or subnormal. The Cl. welchii organisms not only release a myotoxin which breaks down protein to produce gas, but also a haemotoxin which haemo-lyses blood and can cause coagulation failure and haemorrhages. Haemolysis results in severe anaemia, port wine coloured urine and jaundice. The last sign is sometimes a presenting one and can also be the result of liver, spleen and kidneys are affected by the gas-forming organisms and renal failure is common.
The results and its contents also become necrotic and the presence of gas in the foetus and the uterus (physometra) can often be detected by crepitus on palpation, and be demonstrated by radiography.
1. Bacteramic (endotoxic) shock
- Vaginal or cervical swab and prepare cultures
- Estimation of its haemoglobin and cellular contents
- Blood for culture
- Mid-stream specimen of urine
2. Isolation of the patient : Ideally be isolated
4. Blood transfusion
5. Evacuation of the uterus
6. Other surgical procedures
7. Treatment of shock
8. Treatment of oliguria