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 . 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 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 . 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 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- . 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. The hemoglobin level was the 10th hospital day digitalization was insti- 9.2 grams/100 ml., with a hematocrit level of tuted with Lanoxin 0.75 mg. every 6 hours. 33 per cent. Soft, small, fluctuant skin lesions Some slow clinical improvement was noted appeared on the soles of the feet and on the until the thirteenth hospital day, when pete- forehead. These later proved to be embolic ab- chiae appeared on the anterior surface of the scesses from which Aerobacter aerogenes and

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anaerobic beta Streptococcus were cultured. patient admit to any criminal attempt al- For the next 5 days, clinical improvement though criminal intervention was suspected was noted and the steroids were gradually de- from the apparently poor marital relationship creased. of the patient and her husband, who was ex- On the thirty-fourth hospital day hemopty- tremely hostile. sis occurred, accompanied by chest pain which The most common organisms found in sep- was aggravated by coughing. Severe dyspnea tic abortion are the gram-negative bacteria- and tachycardia were present. Serial electro- Escherichia coli, Aerobacter aerogenes, and cardiograms revealed diffuse sub-epicardial Pseudomonas aeruginosa; the gram-positive ischemia and low voltage QRS complexes. anaerobic non-hemolytic streptococci; Clostrid- Consolidation of the left lower lung was ium welchii; and recently staphylococci. 6 The present by the thirty-sixth hospital clay with organisms gain entrance by instrumentation an interlobar collection of fluid on the right. or after premature rupture of membranes, Thoracentesis was performed and approxi- causing a necrotizing endometritis and decidu- mately 200 ml. of green, purulent fluid was ob- itis at the placental site. Microscopically one tained. Tube thoracostomy was performed 2 sees an inflammatory exudate; the decidua con- days later. Cultures revealed anaerobic beta tains leukocytes and plasma cells, and exten- Streptococcus and Aerobacter aerogenes sensi- sive necrosis and thrombosis of the small ves- tive to the antibiotics being used. Oliguria and sels occurs. Multiple small abscesses develop cardiac failure developed despite therapy. The in the myometrium. These abscesses can dis- patients condition deteriorated and she died seminate bacteria via the small veins and on the forty-second hospital day. Permission lymphatics which drain laterally to the ovar- for postmortem examination was not granted. ian veins and lymphatics into the general cir- culation.6 The uterus demonstrates cytolysis Discussion and edema, which often accounts for the soft, Attention in this case first centered on the re- boggy texture on palpation. Post-abortal phleg- moval of the focus of infection and then on the mons may develop within the leaves of the control of the disseminated infection. The pa- broad ligaments and point intraperitoneally tient did not present with the typical clinical above the level of the inguinal ligament. In picture of , chills, prostration, peritonitis, this case, the effects of venous and lymphatic and/or shock. She did present with heavy spread were demonstrated by the septicemia, vaginal bleeding and mild disorientation, which diffuse pelvic cellulitis, and salpingitis. was thought to result from due to The entrance of the bacteria, especially the blood loss. According to the classification of gram-negative organisms, into the general cir- septic abortion presented by Little this pa- culation is accompanied by the release of endo- tient had stage I. Her condition did not satisfy toxins which lead to endotoxic shock. In many the criterion of Grover 5 : "Any abortion ac- series, the mortality rate in endotoxic shock companied by a fever of 101 F at any time or exceeds 65 per cent. Acute renal failure may 100.4 F on two successive days is to be con- be the result of endotoxic shock. If shock, in sidered a septic abortion." septic abortion, occurs out of proportion to the There was a discrepancy between the gesta- blood loss, endotoxins are the prime etiologic tional age and fetal size. At no time did the consideration. The mechanism of this type of

810/86 shock is probably correlated with a diminished fibrin thrombi but also the normal clotting fac- peripheral resistance with visceral "pooling" tors may be destroyed and a hemorrhagic state and vascular sludging, together with an in- produced.18 Administration of the fibrinolysin creased cardiac output( The sludging is pro- inhibitors and heparin is of value in such cases. duced by the Shwartzman phenomenon, which Heparinization followed by administration of occurs mainly in the kidneys. The endotoxins fibrinogen will serve to correct the hemorrhag- cause progressive elevation of circulating ic state and the intravascular clotting proc- catecholamines, which in turn stimulate the ess by preventing conversion of fibrinogen to alpha-adrenergic receptor sites in the glomeru- fibrin. lar capillaries. In the presence of a hyperco- Clostridial infections can cause a hyperco- agulable state such as pregnancy, deposition of agulable state by hemolyzing the erythrocytes fibrin then occurs with resultant intravascular and thus releasing thromboplastic substance. clotting.8 Endotoxemia is followed by a lower- Oliguria and hemoglobinuria result in addition ing of the levels of the platelets, fibrinogen, and to the other signs of a clotting derangement. Factors VIII and IX, predominantly as a re- Another complication of septic abortion is sult of their utilization in the intravascular thrombophlebitis of the pelvic veins. Emboliza- clotting process.9 Initially the coagulation time tion can disseminate infected emboli to the is shortened, and later it is prolonged. In the lung, brain, kidney, liver, heart valves, and study reported by Muller-Berghaus and co- skin. At times it may be necessary to ligate the workers,8 the generalized Shwartzman phe- inferior vena cava and infundibulopelvic liga- nomenon was elicited in pregnant rats by a ments. This procedure can be lifesaving when single injection of bacterial endotoxin. "The embolic showers continue despite conserva- placenta and decidua contain more thrombo- tive therapy. This patient clearly demon- plastic activity by far than any other tissue in strated embolization to the lungs and skin and the body." probably to the other aforementioned areas The clinical picture of endotoxic shock with of the body. Unfortunately, there are no its high mortality rate is that of hypotension, clear-cut signs of a forming pelvic thrombo- anemia, thrombocytopenia, subnormal temper- phlebitis until embolization occurs. Pain is atures, peripheral vascular collapse, and ap- frequently absent. However, recurring bouts prehension. This patient demonstrated various of a spiking kind of fever and shaking chills degrees of apprehension and was intermittent- may occur when these embolic showers are set ly hypotensive and persistently anemic. If free. These symptoms, together with a cor- renal cortical necrosis occurs, a reduction of responding elevation of the pulse rate, which the urinary output ensues as a result of the is sustained and does not slow with the fall in plugging of the glomerular arterioles with the temperature, strongly suggest pelvic fibrin thrombi and consequent necrosis. Not thrombophlebitis.3 infrequently the patient with endotoxic shock dies before the clinical picture of acute renal Management necrosis appears. When a presumptive diagnosis of septic abor- Activation of the fibrinolytic system occurs tion has been made, evaluation of the patient with a hypercoagulable state. The lytic process should include, in addition to adequate history- may become so extensive that not only the taking and physical examination, the follow-

Journal AOA/vol. 66, April 1989 811/87 Septic abortion

ing studies: Complete blood count; blood cul- whose infection is confined to the uterus tures, both aerobic and anaerobic; urinalysis, present with the history of having passed the urine culture, and testing for hemoglobinuria; entire conceptus and exhibit a slightly bloody electrolyte, blood urea nitrogen, and serum rather than bleeding. In dif- bilirubin determinations; fibrinogen index and ferentiating these patients from those whose testing for fibrinolysin activity; vaginal smears infection is no longer confined to the uterus, for gram stain and culture; scout abdominal the decisive factor is the degree of pelvic floor and chest x-rays; and testing of clotting time. tenderness on vaginal and rectal examination. A pregnancy test is of questionable value. Parsons and Sommers3 considered dilatation Treatment is directed primarily against the and curettage to be unnecessary in most cases, infection. This patient was allergic to the stating that supportive treatment and antibi- and therefore Terramycin and otic therapy are usually sufficient. I differ with Chloromycetin were administered. The tetra- this view, having observed that many patients cyclines may be preferred because of the he- with "complete" abortions return some weeks matologic effect of Chloromycetin. According later with erratic vaginal bleeding unrespon- to Parsons and Sommers,3 the type of man- sive to conservative therapy and sufficient to agement of septic abortion depends on whether require curettage. the abortion is complete or incomplete and on The most critical group of patients are those whether infection has become extrauterine. with pelvic inflammation following infection Of patients with septic abortion, between 75 after an incomplete or complete abortion. In and 90 per cent will have an incomplete abor- the great majority of cases, the abortion is tion with infection limited to the uterus. These incomplete. Most nationwide statistics support patients are not acutely ill. The temperature this finding and are in agreement on the inci- is rarely over 103 F.; tachycardia is present. dence. The normal dilation of the pelvic veins Excessive vaginal bleeding is rare. Cramping during pregnancy aids the spread of the infec- suggests that the abortion is incomplete. There tion. Conservative therapy directed toward is abdominal wall tenderness when the uterus control of the infection and the metabolic/ is pressed against the sensitive parietal peri- hematologic picture is of prime importance. toneum but if the uterus is only moved with Transfusion may be necessary, not only to cor- the examining finger, the tenderness is present rect the anemia due to blood loss, but also to only in the uterus. Rectal examination reveals combat the hemolysis of the erythrocytes re- no lateral tenderness or thickening. These pa- sulting from the toxic effects of sepsis. Main- tients are best treated by early emptying of the taining proper electrolyte balance with intra- uterus since the infection will spread. Peni- venous fluids is important as these patients cillin is administered initially in a dosage of are often dehydrated and exhibit electrolyte 600,000 units intravenously, followed by 300,- imbalance on a renal and gastrointestinal 000 units intramuscularly every 4 hours there- basis. Ileus is common and must have prompt after combined with Streptomycin 0.5 gram and proper attention. Fowlers position is rec- every 12 hours intramuscularly. After the an- ommended as it promotes the collection of the tibiotic regimen has been in effect at least 12 exudates in the cul-de-sac. Routine supportive hours, dilatation and curettage is performed. measures are instituted. Of utmost importance The patients whose abortion is complete and is a high index of suspicion which will insure

812/88 early recognition of the onset of complications. They aggravate the excessive vasoconstriction Russell and associates noted septic abortion to caused by the endotoxin. However, Sweeney be "by far, the primary condition predisposing and Rodgers pointed out that metaraminol to acute renal failure in the first trimester of (Aramine) mobilizes pooled blood and in- pregnancy. creases the venous return in patients with en- Several investigators have demonstrated the dotoxic shock. They recommended that metara- value of the corticosteroids in the treatment of minol be given in a dose sufficient to keep the septic abortion. Antibiotic therapy may initial- systolic blood pressure at about 20 to 30 mm. ly cause intensification of shock because the Hg below the preshock level, and stated that rapid destruction of organisms results in the optimal benefits are thus obtained without ex- release of large amounts of endotoxin. The cessive vasoconstriction. corticosteroids offer protection from the ef- However, recent reports, including the re- fects of the endotoxin, presumably by sup- port of Martinez and his associates, 12 attest to pressing the hosts response to the endotoxin. the advantages of vasodilators. The results of According to Sweeney and Rodgers, the in- a study employing vasoconstrictors to treat crease in cardiac output and decrease in shock in septic abortion13 stimulated an in- peripheral resistance also produced by corti- vestigation of the therapeutic efficacy of vaso- costeroid therapy may be an even greater bene- dilators in the same clinical situation. 12 The fit. The increase in adrenal hormonal secre- drugs employed for vasodilation were Dibenzy- tion which occurs during endotoxic shock line, an alpha-adrenergic blocking agent, 8 and supports the conclusions regarding the worth a "lithic cocktail" containing Demerol 100 mg., of steroid therapy. Administration of corti- Thorazine 50 mg., and Compazine 25 mg. Di- costeroids is continued for 24 to 48 hours after benzyline was administered orally in one dose the blood pressure has returned to normal and of 1 mg./kg. of body weight. The "cocktail" remained so without the use of vasopressor was injected intravenously, 1 ml. every 15 drugs. No real benefit from the use of corti- minutes until the total volume (6 ml.) had costeroids has been observed in bacteremia un- been administered. Then, the same dose of the complicated by shock. mixture was dissolved in 500 ml. of an isotonic A wide range of agents have been used for glucose solution and injected by venoclysis antibiotic therapy, but some of those employed every 12 hours. Comparison of the patients are specific for the gram-negative organisms. receiving Dibenzyline with those receiving the The use of in dosages of 30 to 60 "lithic cocktail" showed Dibenzyline to have million units per day is common. Penicillin G a much longer duration of action. Also, it was in dosages of 5 to 20 million units is needed to easier to handle. A third group received vaso- produce serum levels high enough to inhibit constrictors. All patients received heparin and some of the coliform organisms. The use of antibiotics and submitted to surgical proce- Streptomycin is questionable because the ma- dures, and all but one received corticosteroids. jority of strains of the Klebsiella/Aerobacter Martinez and his co-workers 12 found that the group are resistant to it. Most strains are sen- clinical resolution of the cases treated with sitive to Kantrex, Coly-Mycin, and Polymyxin. vasodilators was superior to that of those The use of vasoconstrictors in the manage- treated with vasoconstrictors. The earlier ment of endotoxic shock is still controversial. study," which had utilized vasoconstrictors

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exclusively in a regimen otherwise almost cludes intensive organism-specific antibiotic identical, demonstrated a mortality rate of therapy, surgical removal of the focus of in- 41.6 per cent, while the study in which vaso- fection, transfusion when anemia exists, ad- dilators were employed showed a mortality ministration of vasodilators instead of vaso- rate of 5.5 per cent. Investigations involving constrictors for shock, corticosteroid therapy, larger numbers of patients treated with vaso- anticoagulation in the presence of a hyper- dilators are necessary for more adequate eval- coagulable state, and general supportive care. uation. The case reported is a tragic reminder of the Hypothermia is of value in the patient with seriousness of this disease entity. hyperpyrexia in endotoxic shock because low- ering the body temperature alters the meta- Appreciation is expressed to Dr. Harvey C. Orth, Jr., bolic processes of both the bacteria and the chairman, Department of Obstetrics and Gynecology, and to Dr. Sidney J. Katz, chairman, Department of host. Pathology, Riverside Osteopathic Hospital, Trenton, When clostridial infections are present, Michigan. large doses of antitoxin and antibiotics are indicated and intermittent hyperbaric oxygen- 1. Taylor, E. S.: Essentials of gynecology. Ed. 3. Lea Febiger. ation may be helpful. This latter adjunct has Philadelphia, 1965, D. 333 2. Bonnano, J. P.: Septic abortion. Michigan Osteopath J 33:13, not yet been thoroughly evaluated. Early hy- Feb 68 sterectomy may be indicated in clostridial in- 3. Parsons, L., and Sommers, S. C.: Gynecology. W. B. Saunders fections. Co., Philadelphia. 1962 4. Little, B.: Intrauterine infections in obstetrics. In Advances in The Trendelenburg position is mentioned obstetrics and gynecology, edited by S. L. Marcus and C. C. Mar- cus. Williams Wilkins Co., Baltimore, 1967, vol. 1 only to condemn it. 5. Grover. J. W.: Gynecological emergencies. Surg Clin N Amer Central venous pressure monitoring per- 46:665-83, Jun 66 6. Kistner, R. W.: Gynecology: Principles and practice. Year Book formed concomitantly with hourly measure- Medical Publishers, Inc., Chicago, 1964 ment of urinary output aids greatly in assess- 7. Sweeney, F. .1., and Rodgers, J. F.: Therapy of infections caused by gram-negative bacilli. Med Clin N Amer 49:1391-1402, ing the renal status. Sep 65 8. Muller-Berghaus, G., Davidson, E., and McKay. D. G.: Preven- tion of the generalized Shwartzman reaction in pregnant rate by Summary alpha-adrenergic blockade. Effects on the coagulation mechanism. Septic abortion continues to be one of the ma- Obstet Gynec 30:774-8, Dec 67 9. Margaretten, W., and McKay, D. G.: The generalized Shwartz- jor causes of maternal death. Sepsis caused man reaction in pregnancy. In Advances in obstetrics and gyne- cology, edited by S. L. Marcus and C. C. Marcus. Williams Wil- by the gram-negative bacteria poses a serious kins Co., Baltimore. 1967, vol. 1 therapeutic dilemma. 10. Phillips, L. L., Skrodelis, V., and Quigley, H. J., Jr.: Intra- vascular coagulation and fibrinolysis in septic abortion. Obstet A case of presumed incomplete abortion is Gynec 30:350-61, Sep 67 presented. Sepsis due to Aerobacter aerogenes 11. Op. cit., ref. 9, p. 183 caused the patients death despite antibiotic 12. Martinez, J. T., Fernandez, G., and Vazquez-Leon, H.: Clinical evaluation of new therapeutic concepts in . Obstet therapy. This patient demonstrated several of Gynec 27:296-301. Feb 66 13. Martinez, J. T., and Fernandez, G.: Shock bacteraemico en the characteristics of a complicated case of obstetricla. Rev Obstet Ginec Venez 22:455-73, 1962 septic abortion; but only terminally, and after a prolonged period of hospitalization, did renal 1969 Philips Roxane Resident Award paper, written during Dr. Bak- failure develop. The clinical picture of endo- ers residency in the Department of Obstetrics and Gynecology at Riverside Osteopathic Hospital, Trenton, Michigan, of which Dr. toxic shock was not classically demonstrated. Harvey C. Oral, Jr., was chairman.

Therapy in complicated septic abortion in- Dr. Baker. 381 Chestnut Street, Union, New Jersey 07083.

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