Postpregnancy Genital Tract and Wound Infections

Nell Tharpe, CNM, CRNFA, MS

Disclosures

J Midwifery Womens Health. 2008;53(3):236-246. 

In This Article

Postabortion Infection

The complications addressed in this section can occur following spontaneous or missed abortions, or following medical or surgical elective termination of pregnancy. While serious complications secondary to spontaneous, medical and surgical abortion are uncommon in developed countries, severe infection can occur. Complications such as hemorrhage from trauma or uterine atony, incomplete abortion, and inadvertent perforation of the uterus and/or other organ during instrumentation of the uterus, increase the risk of developing postabortion infection.[50]

Several deaths related to rare infection with Clostridium sordellii, a Gram-positive, toxin-forming, anaerobic bacterium, following medical abortion have been documented in the United States and Canada in women who exhibited clinical illness consistent with toxic shock in the presence of endometritis.[51]

Most elective abortions, both surgical and medical, are obtained by single women under 25 years of age who are 8 or fewer weeks' gestation. The majority of abortions continue to be performed surgically by curettage, but the medical abortion rate for early pregnancy (≤8 weeks) has risen to approximately 12%.[52] Infection is considered a delayed complication of abortion and occurs in 0.1% to 4.7% of women who undergo first-trimester abortions. These infections are usually secondary to pre-existing genital tract infection, retained products of conception, or instrumentation of the uterus.[53]

Prophylactic antibiotics, such as oral doxycycline 100 mg 1 hour before the procedure followed by 200 mg postprocedure, are the standard of care for women undergoing surgical abortion or dilation and curettage (D&C).[54] Antibiotic prophylaxis is not indicated for women who undergo successful medical abortion or complete spontaneous abortion that does not require D&C.[54,55]

Lower abdominal discomfort is not uncommon following abortion, and in the woman who is afebrile with no other signs or symptoms, it is commonly treated with expectant management. While a localized inflammatory reaction of the endometrium may occur following abortion, it must be differentiated from moderate or severe endometritis, pelvic abscess, and peritonitis or septic abortion, which present with fever, abdominal pain, foul-smelling vaginal discharge, and prolonged or heavy bleeding.[50] Women who present with these signs and symptoms require further evaluation for uterine tenderness, pelvic mass, and signs of systemic illness. Women requiring further evaluation and treatment are referred to a physician capable of performing dilatation and curettage or other procedures as necessary.[50,54] Appropriate testing and cultures are performed based on the woman's clinical presentation and may include Gram stain of cervicovaginal secretions; bacterial vaginosis, chlamydia and gonorrhea testing; and cultures of cervical secretions, blood, and products of conception. Ultrasound evaluation may be performed to determine the presence of retained products of conception.[50]

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