uterine wall infection as result of self induced abortion

The patient presents with signs and symptoms of septic shock with examination findings localizing the source of septic shock potentially to a pelvic organ. A number of notable features suggest specifically the uterus as a potential source of infection, including a tender uterine fundus, discharge from the cervical os, a dusky appearance to the cervix suggesting a necrotizing infection, and a linear laceration of the cervix. The patient’s septic shock is also complicated by acute hypoxemic respiratory failure and ARDS, an elevated lactate level, and laboratory test results concerning for a possible microangiopathic hemolytic anemia such as disseminated intravascular coagulation. Given the recent positive pregnancy test, marked severity of illness with septic shock and ARDS, and physical examination results that suggest both uterine infection and trauma, a complication of an unsafe and self-managed abortion should be considered as a potential diagnosis.

Approximately 2% to 7% of women in the United States seeking abortion services report attempts to self-induce abortion, which can include methods of ingestion of substances such as medications, herbs, or illicit substances or the vaginal insertion of foreign objects aimed to physically disrupt the pregnancy, as suggested in this case with the examination finding of a linear laceration of the cervix. When infectious complications of unsafe and self-managed abortions arise, these most commonly include endometritis, pelvic abscess, bowel perforation, or a necrotizing infection of the uterine wall as noted by a dusky appearance of the cervix. The organisms most commonly causing these infections include Enterobacteriaceae, Streptococcus, methicillin-sensitive Staphylococcus aureus, and Listeria monocytogenes. Clostridial species such as Clostridium perfringens can cause uterine myonecrosis in the setting of unsafe abortions and also cause features seen in this case such as hemolytic anemia with disseminated intravascular coagulation, septic shock, and ARDS. Given these common pathogens implicated in patients with possible infectious complications of unsafe and self-managed abortion and the possibility of clostridial sepsis in this patient suggested by her severity of illness, the recommended empiric antibiotic treatment regimen is parenteral ampicillin, clindamycin, and gentamicin (choice B is correct). In patients with infectious complications of unsafe abortions, this empiric regimen is reported to be most likely to include an antibiotic to which the causative organism is sensitive. Finally, in this life-threatening condition, source control should be emergently considered for uterine myonecrosis with hysterectomy.

Methicillin-resistant S aureus (MRSA) is not a common cause of infection in the setting of unsafe abortion. In addition, although cefepime would treat the most of the common gram-negative organisms and sensitive gram-positive organisms implicated here, vancomycin and cefepime provide unnecessary MRSA coverage and lack coverage for anaerobic organisms such as clostridial species (choice A is incorrect). Ceftriaxone and doxycycline are recommended for treatment only in the outpatient setting when cervicitis is thought to be due to Neisseria gonorrhoeae or Chlamydia trachomatis (choice C is incorrect). Finally, sulfamethoxazole-trimethoprim would cover most of the gram-negative and gram-positive organisms listed here but would not provide coverage for clostridial organisms (choice D is incorrect).

Unsafe or self-managed abortions can lead to infections of pelvic structures, most commonly by gram-negative, sensitive gram-positive, or anaerobic organisms, and is managed empirically with ampicillin, gentamicin, and clindamycin and urgent consideration of source control in the setting of life-threatening infection.12345

Footnotes

  1. SEEK Questionnaires ↩

  2. Decker WH, Hall W. Treatment of abortions infected with Clostridium welchii. Am J Obstet Gynecol. 1966;95(3):394-399. PubMed ↩

  3. Fouks Y, Samueloff O, Levin I, et al. Assessing the effectiveness of empiric antimicrobial regimens in cases of septic/infected abortions. Am J Emerg Med. 2020;38(6):1123-1128. PubMed ↩

  4. Harris LH, Grossman D. Complications of unsafe and self-managed abortion. N Engl J Med. 2020;382(11):1029-1040. PubMed ↩

  5. Pritchard JA, Whalley PJ. Abortion complicated by Clostridium perfringens infection. Am J Obstet Gynecol. 1971;111(4):484-492. PubMed ↩