If a patient with an incomplete abortion has fever and pus discharging from her cervix, the products of conception have become infected. This can follow a neglected spontaneous abortion, or it can follow unskilled interference. Fortunately, the uterus is usually a good barrier to the spread of infection, but it does sometimes spread as pelvic cellulitis or peritonitis. You can usually treat her without a laparotomy, although you will usually need to evacuate her uterus. If she has peritonitis you will have to open her abdomen.
The diagnosis is usually easy[md]if her history is clear and she is obviously pregnant. Unfortunately, she may be so frightened that she will deny having tried to procure an abortion, even when she is very ill. The only way to avoid a misdiagnosis is to remember that any acute pelvic inflammation in a woman of childbearing age may be the result of an abortion.
Try to control both haemorrhage and infection before you empty her uterus, usually after about 24 hours on antibiotics. Rarely, a hysterectomy may be the only way to save her life. The great dangers are septic shock (53.4) and renal failure (53.3).
IF SHE IS OF CHILDBEARING AGE, IS HER PELVIC INFLAMMATION THE RESULT OF AN ABORTION?
SEPTIC ABORTION See also Section 6.6.
THE DIAGNOSIS should not be difficult. A patient becomes ill and febrile ([mt]38[de]C) after an abortion. She has a foul vaginal discharge, and sometimes frank pus. Examine her vaginally in the ward. If you have the necessary facilities, start by taking an endocervical swab for culture aerobically and anaerobically (if possible). This is better than a high vaginal one. Take it yourself: if you leave it to a junior nurse, it is likely to be a ''low' one. Then use your fingers to remove any of the products of conception, which will come away easily.
Examine her bimanually. Her uterus is tender, there is tenderness on either side, perhaps with a mass. Sometimes she has local or general peritonitis.
Look also for anaemia, jaundice (caused by septicaemia) and chest signs (septic emboli from thrombophlebitis). Measure her haemoglobin, and take blood for grouping and cross-matching. If possible take blood cultures.
Your main concern will be to know how far infection has spread, and if you should open her abdomen.
If her pulse is over 120 a minute, the infection has probably spread beyond her uterus.
If moving her cervix causes her great pain and her lateral fornices are hot, thickened, and tender, perhaps with a mass, the infection has spread to her pelvic connective tissue (parametritis, uncommon).
If you are uncertain about the diagnosis and she is very sick, resuscitate her, start her on antibiotics, take her to the theatre and aspirate her posterior fornix. A seriously infected uterus can be silent, apart from a very sick patient.
If her history suggests that her uterus has been perforated with some instrument, her prognosis is worse. If it is leaking pus into her peritoneal cavity, you may ultimately have to do a hysterectomy.
RESUSCITATE HER as in Section 6.6. If she has lost blood, transfuse her as necessary (53.2, 53.4). If you have no blood, give her Ringer's lactate or 0.9% saline, or a plasma substitute.
ANTIBIOTICS. Try to prevent the infection spreading beyond her uterus. This risk is greatest when you evacuate it. So always cover evacuation with perioperative antibiotics. They will not control the infection, if infected products of conception remain inside her uterus. So empty it, and don't expect to cure her until you have done so.
If she is not very ill, and there are no signs that infection has spread beyond her uterus, a single broad spectrum antibiotic, such as ampicillin may be enough: (1) Give her ampicillin 500 mg intravenously 4 to 6-hourly. Or, (2) give her benzyl penicillin 600 mg intravenously 6-hourly, with streptomycin 1 g daily intramuscularly. Or, instead of the streptomycin give her gentamicin 80 mg intravenously 8-hourly.
If she is very ill, with signs of spread outside her uterus, she needs parenteral antibiotics[md]see Section 6.6.
ANALGESICS. Give her pethidine.
CONTROLLING BLEEDING. Give her ergometrine with oxytocin (''Syntometrine' 1 ml) intravenously, or ergometrine alone.
EVACUATIION. Opinions differ as to when this should be done. We advise that you do it a few hours after starting antibiotics, and never later than 24 hours after. If she is bleeding seriously, do it immediately. Follow the method in Section 16.2. Her uterus will be infected and soft, so be especially careful not to perforate it. Use a blunt curette. Continue antibiotics after evacuation.
POST-EVACUATION MANAGEMENT. Watch her carefully, especially her urine output. Several things may happen during the next few days. If she is seriously ill, an important decision will be whether or not she needs a laparotomy.
If all is well, she should improve dramatically, and her fever should go in 48 to 72 hours.
If she has not started to improve 24 hours after evacuation, but signs of peritonitis are not obvious, she probably has a pelvic abscess. Take her to the theatre and aspirate her posterior fornix (6.5). Avoid her lateral fornices, or you may injure her ureters or her uterine arteries. If you aspirate pus or blood-stained fluid, drain it through her posterior fornix, as in Section 6.5.
If she has not started to improve 24 hours after evacuation, and signs of generalized peritonitis are obvious (pain, tenderness, rigidity, and abdominal distension), she is in serious trouble. Her uterus may have been perforated by an abortionist, or he may have injected some harmful fluid into her peritoneal cavity. She needs a difficult laparotomy. Refer her if you can. Improve her general condition as best you can. Rehydrate her, if necessary, restore her haemoglobin to at least 80 g/l by transfusion, and have at least 2 units of blood available. Then do a laparotomy as in Section 6.6.
DIFFICULTIES [s7]WITH SEPTIC ABORTIONS See also Sections 6.6 and 16.2 (inevitable abortions).
If you are NOT SURE IF SHE HAS PERITONITIS or not, consider waiting 24 hours. If necessary, aspirate her posterior fornix with a needle in the theatre.
If you PERFORATE HER UTERUS when you evacuate a septic abortion, there is no easy answer. If you stop and send her back to the ward incompletely evacuated, she is in danger. If you complete the evacuation, you may spread the infection further. This also is dangerous. As a general rule, if you perforate a pregnant uterus, complete the evacuation as best you can, then do a laparotomy and repair her uterus with a single layer of interrupted silk sutures. For the accidental perforation of a non-pregnant uterus, see Section 20.3.
If her URINE OUTPUT FALLS below 30 ml/hour, her kidneys are probably failing, so see Section 53.3.
If she has signs of SEPTIC SHOCK, treat it (53.4). The signs to watch for are an alert patient with a blood pressure below 80 mm, and a subnormal temperature.
If you feel CREPITATIONS (bubbles of gas in the tissues), suspect GAS GANGRENE and look for gas shadows radiologically. Treat her as in Section 54.13.