Septic Abortion and Maternal Mortality: Report of a Case
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Septic abortion and maternal mortality: A bortion, septic Report of a case NORMAN F. C. BAKER, D.O. Union, New Jersey Septic abortion is a major cause cause of abortion and present a case illustrat- of maternal mortality. In the case ing some of the classic findings. reported here the patient Report of a case died in spite of antibiotic therapy. The A 36-year-old white woman, gravida VI, para 36-year-old woman presented 3-0-2-3, was admitted to the emergency room with heavy vaginal bleeding. The of Riverside Osteopathic Hospital at 8: 00 a.m. gestational age was estimated on April 26, 1967. She complained of vaginal to be 12 weeks. Dilatation and curettage bleeding associated with backache, uterine increased the suspicion of cramping, and dyspnea. She considered the bleeding to be heavy and stated that it had discrepancy between the reported begun spontaneously approximately 4 hours gestational age and actual fetal prior to admission; cramping had ensued short- size. Blood cultures were reported as ly after the onset of bleeding. Dyspnea began growing Aerobacter aerogenes at the time of admission. The first day of the and anaerobic beta Streptococcus, and last menstrual period was estimated as Febru- antibiotic therapy was adjusted ary 2, 1967, the estimated gestational age be- ing 12 weeks. The pregnancy had been un- accordingly. In spite of intensive eventful until this date; we were unable to therapy, oliguria and cardiac elicit any history of criminal intervention. failure developed and the patient died. However, there was some language barrier making interrogation difficult; further, the patient was somewhat disoriented. The gyne- cologic history revealed that menses occurred Abortion, according to Taylor, is defined as every 28 to 35 days with an 8-day flow. The "the expulsion of the products of conception menarche occurred at age 15. No history of before the period of viability." Septic abor- dysmenorrhea or other gynecologic problems tion accounts for more than 50 per cent of was elicited. maternal deaths due to infection each year in The medical and systemic reviews were es- Pennsylvania, Michigan, and New York.2 sentially negative. She was allergic to peni- Aside from idiopathic causes, the etiologic fac- cillin and aspirin. Operations included appen- tors in abortion include a previously ampu- dectomy and adenotonsillectomy. tated cervix, congenitally abnormal uterine Physical examination revealed the patient anatomy, an incompetent internal cervical os, to be asthenic, slightly agitated, and appre- hypothyroidism, hormonal imbalances, dia- hensive. Her temperature was 99.6 F. orally. betes, nephritides, uterine myomas, acute ill- The blood pressure was 88/40 mm. Hg and the ness or severe mental shock, reflex mecha- pulse rate was 104 beats per minute. Dyspnea nisms—accidents or trauma, either sexual or was obvious. A small suprapubic tender mass instrumentation, and chronic infections. Ac- was palpated. No signs of peritoneal irrita- cording to Parsons and Sommers,3 approxi- tion could be elicited. Vaginal examination re- mately 40 per cent of all hospitalized gyne- vealed the vault to be filled with dark, foul- cologic patients will show some evidence of smelling free blood. The cervix was soft and uterine infection. I shall consider the infectious dilated 2 cm. No tissue was protruding from Journal AOA/vol. 68, April 1969 807/83 Septic abortion the external os. The uterus was enlarged to a Postoperative orders included one dose of size compatible with gestation of 14 to 16 Terramycin 100 mg. intramuscularly to be weeks and was tender on motion. Both adnexal followed by 250 mg. orally four times a day. areas were tender on palpation but no masses Administration of routine analgesics and anti- were palpable. Contractions were occurring pyretics (in anticipation of a mild septic every 3 to 4 minutes. A presumptive diagnosis course) was begun and general supportive of incomplete abortion was made. care measures were instituted. Despite ade- The admitting hemogram showed 3,000,000 quate hydration, urinary output was 300 ml. erythrocytes, the hemoglobin value was 8.4 in the first 12 hours postoperatively; Mannitol grams/100 ml., and the hematocrit level was 12.5 grams was given intravenously. The sec- 28 per cent. There were 11,000 leukocytes, ond 12 hours were uneventful with a return to with 1 band form, 86 segmented forms, and 14 normal temperature, pulse, respiration, and lymphocytes. The Lee-White clotting time was urinary output. A regular diet was well re- 13 minutes. The patient had group A, Rh posi- ceived by the patient. A recheck hemogram tive blood. revealed the hemoglobin value to be 10 grams/ Because the patient exhibited impending 100 ml., with a hematocrit level of 32 per cent. shock when first seen, serum albumin, admin- Bleeding was minimal and bowel sounds were istration of 25 grams in 1,000 ml. of isotonic normal. saline, was begun by venoclysis. Whole com- On the second hospital day, the temperature patible blood 500 ml. was administered and rose to 102 F. orally. A blood specimen was Terramycin 100 mg. was given intramuscular- then obtained for culture. A chest x-ray ly. The likelihood of spontaneous abortion was showed streak atelectasis in both lung bases. dubious; therefore, evacuation of the uterus A scout abdominal x-ray was negative for ob- was considered the procedure of choice. No struction. Clinically there was mild to mod- complicating factors were anticipated. Dila- erate hypodynamia which responded to Pro- tation and evacuation of the uterus were car- stigmin and enemas. The urinary output was ried out under sterile conditions, and a sur- 1,800 ml. in the next 24 hours. The lochia was prisingly large amount of necrotic products of scant and dark. conception was removed. The amount height- During the next 2 weeks spiking of the tem- ened awareness of the possible discrepancy perature persisted. The patient was treated between the reported gestational age and ac- with Chloromycetin 1 gram intravenously and tual fetal size. Moderate bleeding being en- 500 mg. orally four times a day. Anemia mani- countered, the anesthesiologist administered fested by hemoglobin 9 to 10 grams lower than Syntocinon, 10 units intravenously and 5 units normal persisted despite the lack of blood loss intramuscularly. A second 500 ml. of blood and the use of replacement therapy. Cultures was transfused. The uterus was not packed be- of the urine and stool showed no growth of cause the bleeding decreased greatly. The pa- pathogens. The blood cultures repeatedly were tient was then transferred to the recovery reported as growing Aerobacter aerogenes and room in satisfactory condition. The blood anaerobic beta Streptococcus. Therapy con- pressure at this time was 90/50 mm. Hg and sisted of Kantrex 250 mg. intramuscularly stable with the pulse rate 110 to 120 beats per every 6 hours and later Coly-Mycin in a dosage minute. of 50 mg. intramuscularly every 12 hours. The 808/84 use of Chloromycetin and Terramycin therapy thorax. Since the petechiae were all above the was re-evaluated and adjusted accordingly. level of the umbilicus, pelvic thromboemboliza- Electrolyte imbalance occurred and appro- tion was a prime consideration. However, on priate measures were carried out for correc- the fourteenth hospital day petechiae appeared tion. Renal function, as determined by the on the legs. The platelet count was now 27,000 blood urea nitrogen level and urinary output, per cubic millimeter and the hemoglobin value was. satisfactory. was 11.4 grams with a hematocrit level of 35 On the fifth hospital day, bilateral pleural per cent. Fibrinolysins could not be demon- effusion was reported and medical consulta strated. The patient became semicomatose. A tion obtained. sternal bone marrow biopsy done to determine Signs of a pelvic abscess appeared. The left the cause of the thrombocytopenia revealed adnexal area was tender and a mass was pres- adequate numbers of megakaryocytes. Predni- ent. Physical findings and x-rays pointed to a sone 20 mg. was administered orally every 6 developing concomitant adynamic ileus. hours. On the eighth hospital day, pelvic laparot- Within the next 4 days clinical improvement omy revealed a diffuse, retroperitoneal cellu- was again discernible from the disappearance litis and pyosalpinx on the right. The broad of the petechiae, resolution of the pneumonia, ligaments bilaterally were indurated and a and improvement in the patients general con- small amount of cloudy fluid was in the cul-de- dition. However, she continued to exhibit a sac. The uterus and remaining pelvic viscera diurnal temperature elevation. appeared unremarkable. The posterior peri- On the twenty-second hospital day an anti- toneum was surprisingly smooth and non-ad- biotic-induced stomatitis appeared which was hesive. Cultures of the right fallopian tube successfully treated with topical gentian vio- and surrounding pelvic viscera were taken and let. On the twenty-third hospital day a peri- grew out Aerobacter aerogenes. The histopath- cardial friction rub occurred which lasted for ologic diagnoses were acute inflammation and approximately 24 hours. Pedal and pretibial microabscess formation of the right fallopian edema developed but responded to diuretic tube. therapy. The pneumonia again became a com- Despite the intensive antibiotic therapy, plicating factor involving both lung fields and pneumonia and bilateral hydropneumothorax requiring oxygen by tent and intermittent pos- developed. The adynamic ileus resolved spon- itive pressure breathing. taneously after the laparotomy. Clinical diffi- A hemogram on the twenty-eighth day re- culty centered around the pneumonitis and vealed 3,500,000 erythrocytes and 30,000 leu- sepsis. Heparinization with Liquaemin was kocytes, with 1 eosinophil, 3 myelocytes, 2 carried out in view of the known frequency of band forms, 82 segmented forms, 9 lympho- occurrence of thrombophlebitis. cytes, and 3 monocytes. Severe toxic granula- Tachycardia and dyspnea developed and on tion was present.