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Emergency Medicine > OBSTETRICS AND GYNECOLOGY
Abortion, Septic
Article Last Updated: Aug 29, 2006
AUTHOR AND EDITOR INFORMATION
Section 1 of 10  
Author: Slava V Gaufberg, MD, Assistant Professor of Medicine, Harvard Medical School; Associate Chief, Research Director, Director of Education and Training, Department of Emergency Medicine, The Cambridge Hospital
Slava V Gaufberg is a member of the following medical societies: American College of Emergency Physicians
Editors: Roy Alson, MD, PhD, FACEP, FAAEM, Associate Professor, Department of Emergency Medicine, Wake Forest University School of Medicine; Medical Director, Forsyth County EMS; Deputy Medical Advisor, North Carolina Office of EMS; Associate Medical Director, North Carolina Baptist AirCare; Francisco Talavera, PharmD, PhD, Senior Pharmacy Editor, eMedicine; Mark Zwanger, MD, MBA, Assistant Professor, Department of Emergency Medicine, Thomas Jefferson University; John D Halamka, MD, MS, Associate Professor of Medicine, Harvard Medical School, Beth Israel Deaconess Medical Center; Chief Information Officer, CareGroup Healthcare System and Harvard Medical School; Attending Physician, Division of Emergency Medicine, Beth Israel Deaconess Medical Center; Pamela L Dyne, MD, Associate Professor, Program Director, Department of Medicine, Division of Emergency Medicine, University of California at Los Angeles School of Medicine
Author and Editor Disclosure
Synonyms and related keywords:
miscarriage, spontaneous abortion, therapeutic abortion, artificial abortion, pelvic infection, pelvic inflammatory disease, PID, miscarriage
Background
A septic abortion is a spontaneous or therapeutic/artificial abortion complicated by a pelvic infection.
Pathophysiology
Infection usually begins as endometritis and involves the endometrium and any retained products of conception. If not treated, the infection may spread further into the myometrium and parametrium. Parametritis may progress into peritonitis. The patient may develop bacteremia and sepsis at any stage of septic abortion. Pelvic inflammatory disease (PID) is the most common complication of septic abortion.
Mortality/Morbidity
- Septic abortion was once the leading cause of maternal death around the world. The condition remains a primary cause of maternal mortality in the developing world, mostly as a result of illegal abortions.
- In the US, mortality from septic abortion rapidly declined after legalization of abortion. Death now occurs in less than 1 per 100,000 abortions. Figures for most European countries are similar to US rates.
- The risk of death from septic abortion rises with the progression of gestation.
History
- Any woman of childbearing age presenting with fever, abdominal pain, vaginal discharge, or vaginal bleeding should be evaluated for a possible septic abortion.
- Patients with septic abortion usually present with complaints including the following:
- Fever
- Abdominal pain
- Vaginal discharge
- Vaginal bleeding
- History of recent pregnancy
Physical
- Perform an abdominal examination with attention to guarding, rebound tenderness, and bowel sounds.
- Perform a pelvic examination to assess vaginal discharge, bleeding, cervical motion tenderness, uterine and adnexal tenderness, and masses.
Causes
Two major factors contribute to development of septic abortion.
- Retained products of conception due to incomplete spontaneous or therapeutic abortion
- Introduction of infection into the uterus - Pathogens causing septic abortion usually are mixed and derived from normal vaginal flora and sexually transmitted bacteria. These organisms include the following:
- Escherichia coli and other aerobic, enteric, gram-negative rods
- Group B beta-hemolytic streptococci
- Staphylococcal organisms
- Bacteroides species
- Neisseria gonorrhoeae
- Chlamydia trachomatis
- Clostridium perfringens
- Mycoplasma hominis
- Haemophilus influenzae
Appendicitis, Acute
Pelvic Inflammatory Disease
Pregnancy, Ectopic
Pregnancy, Trauma
Pregnancy, Urinary Tract Infections
Shock, Septic
Urinary Tract Infection, Female
Vaginitis
Vulvovaginitis
Lab Studies
- Complete blood count
- Erythrocyte sedimentation rate
- Beta-human chorionic gonadotropin; quantitative levels may provide a basis for future comparison
- Electrolytes, glucose, BUN, and creatinine
- Blood type and screen
- Endocervical cultures (eg, aerobic, anaerobic, gonorrheal, chlamydial) and Gram stain
- Blood cultures
Imaging Studies
- Perform an ultrasound examination to identify retained products of conception in the uterus, adnexal masses, and free fluid in the cul-de-sac.
- Both supine and upright radiographs of the abdomen assist in detection of free air or foreign bodies. Perform an exploratory laparotomy if a large amount of free air under the diaphragm is accompanied by fever, chills, vaginal bleeding, and abdominal pain.
Prehospital Care
- Monitor vital signs.
- Stabilize with IV fluids (eg, normal saline, Ringer lactate).
- Administer oxygen.
Emergency Department Care
- Administer IV fluids through a large-bore angiocatheter.
- For patients who are unstable, administer oxygen and insert a Foley catheter.
- Early antibiotic treatment may be guided by Gram stain, but broad-spectrum coverage is recommended.
- Perform evacuation of retained tissues from the uterine cavity, preferably by dilation and curettage (D&C). If D&C is not immediately available, high doses of oxytocin can be used.
- Laparotomy may be needed if the above measures elicit no response.
- A hysterectomy may be necessary in cases of uterine perforation, bowel injury, clostridial myometritis, and pelvic abscess.
- Management of septic shock is discussed in Septic Shock.
Consultations
- Consult obstetrics and gynecology (OB/GYN) as soon as possible.
Aggressive antimicrobial therapy prevents death by eliminating all septic sources during the early stages of the disease.
Drug Category: Antibiotics
Therapy must cover all likely pathogens in the context of the clinical setting. Once sensitivities are known, the use of antibiotic monotherapy is recommended.
| Drug Name | Doxycycline (Bio-Tab, Doryx, Vibramycin) |
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| Description | Used for treatment of infections caused by susceptible gram-negative and gram-positive organisms, in addition to infections caused by susceptible Rickettsia, Chlamydia, and Mycoplasma species. |
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| Adult Dose | 100 mg doxycycline IV q12h with 2 g cefoxitin IV qid; administer for at least 4 d and for at least 48 h after patient improves; PO doxycycline (100 mg) should then be administered bid for a total of 10-14 d |
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| Pediatric Dose | <12 years: Not established
>12 years: 2-5 mg/kg/d in 1-2 divided doses; not to exceed 200 mg/d |
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| Contraindications | Documented hypersensitivity, severe hepatic dysfunction |
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| Interactions | Bioavailability decreases with antacids containing Al, Ca, Mg, Fe, or Bi subsalicylate; tetracyclines can increase hypoprothrombinemic effects of anticoagulants; tetracyclines can decrease effects of PO contraceptives, causing breakthrough bleeding and increased risk of pregnancy |
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| Pregnancy | D - Unsafe in pregnancy
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| Precautions | Photosensitivity may occur with prolonged exposure to sunlight or tanning equipment; reduce dose in renal impairment; consider drug serum level determinations in prolonged therapy; tetracycline use during tooth development (last half of pregnancy through age 8 y) can cause permanent discoloration of teeth; Fanconilike syndrome may occur with outdated tetracyclines |
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| Drug Name | Cefoxitin (Mefoxin) |
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| Description | Second-generation cephalosporin indicated for the management of infections caused by susceptible gram-positive cocci and gram-negative rods. Many infections caused by gram-negative bacteria that are resistant to some cephalosporins and penicillins respond to cefoxitin. |
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| Adult Dose | 2 g cefoxitin IV q6h with 100 mg doxycycline q12h; administer for at least 4 d and for at least 48 h after patient improves
Alternatively, 100 mg PO bid for 10-14 d |
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| Pediatric Dose | <12 years: Not established
>12 years: 80-160 mg/kg/d divided q4-6h; increase dose for more severe or serious infections; not to exceed 12 g/d |
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| Contraindications | Documented hypersensitivity |
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| Interactions | Probenecid may increase effects of cefoxitin; coadministration with aminoglycosides or furosemide may increase nephrotoxicity (closely monitor renal function) |
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| Pregnancy | B - Usually safe but benefits must outweigh the risks.
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| Precautions | Bacterial or fungal overgrowth of nonsusceptible organisms may occur with prolonged use or repeated treatment; caution in patients with previously diagnosed colitis |
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| Drug Name | Gentamicin (Gentacidin, Garamycin) |
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| Description | Aminoglycoside antibiotic for gram-negative coverage. Used in combination with both an agent against gram-positive organisms and one that covers anaerobes.
Not DOC. Consider if penicillins or other less toxic drugs are contraindicated, when clinically indicated, and in mixed infections caused by susceptible staphylococci and gram-negative organisms.
Dosing regimens are numerous; adjust dose based on CrCl and changes in volume of distribution. May be given IV/IM. |
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| Adult Dose | Serious infections and normal renal function: 3 mg/kg/d IV/IM q8h
Life-threatening infections: 5 mg/kg/d IV/IM q6-8h
Loading dose: 1-2.5 mg/kg IV q8h
Maintenance dose: 1-1.5 mg/kg IV q8h |
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| Pediatric Dose | >12 years: 1.5-2.5 mg/kg/dose IV/IM q8h or 6-7.5 mg/kg/d IV/IM divided q8h
Not to exceed 300 mg/d with adjustments for renal function prn |
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| Contraindications | Documented hypersensitivity; non–dialysis-dependent renal insufficiency |
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| Interactions | Coadministration with other aminoglycosides, cephalosporins, penicillins, and amphotericin B may increase nephrotoxicity; aminoglycosides enhance effects of neuromuscular blocking agents; thus prolonged respiratory depression may occur
Coadministration with loop diuretics may increase auditory toxicity of aminoglycosides; possible irreversible hearing loss of varying degrees may occur (monitor regularly) |
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| Pregnancy | C - Safety for use during pregnancy has not been established.
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| Precautions | Narrow therapeutic index (not intended for long-term therapy); caution in renal failure (not on dialysis), myasthenia gravis, hypocalcemia, and conditions that depress neuromuscular transmission; adjust dose in renal impairment |
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| Drug Name | Ticarcillin and clavulanate potassium (Timentin) |
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| Description | Used as presumptive therapy prior to identification of organisms. Inhibits biosynthesis of cell wall mucopeptide and is effective during stage of active growth. |
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| Adult Dose | <60 kg: 200-300 mg/kg/d IV divided q4-6h
>60 kg: 3.1 g IV q4-6h; not to exceed 18-24 g/d |
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| Pediatric Dose | Administer as in adults |
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| Contraindications | Documented hypersensitivity; severe pneumonia, bacteremia, pericarditis, emphysema, meningitis, and purulent or septic arthritis should not be treated with PO penicillin during acute stage |
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| Interactions | Tetracyclines may decrease effects of ticarcillin; high concentrations of ticarcillin may physically inactivate aminoglycosides if administered in same IV line; effects when administered concurrent with aminoglycosides are synergistic; probenecid may increase penicillin levels |
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| Pregnancy | B - Usually safe but benefits must outweigh the risks.
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| Precautions | Perform CBCs prior to initiation of therapy and at least weekly during therapy; monitor for liver function abnormalities by measuring AST and ALT during therapy; exercise caution in patients diagnosed with hepatic insufficiencies; perform UA, BUN, and creatinine determinations during therapy and adjust dose if values become elevated; monitor blood levels to avoid possible neurotoxic reactions |
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| Drug Name | Imipenem and cilastatin (Primaxin) |
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| Description | For treatment of multiple organism infections in which other agents do not have wide-spectrum coverage or are contraindicated due to potential for toxicity.
Initial dose should be based on severity of infection and should be administered in equally divided doses. |
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| Adult Dose | 250-500 mg IV q6h; not to exceed 3-4 g/d
Alternatively, administer 500-750 mg IM/intra-abdominally q12h |
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| Pediatric Dose | <12 years: Do not administer
>12 years: 10-25 mg/kg/dose IV q6h
Fully susceptible organisms: Not to exceed 2 g/d
Moderately susceptible organisms: Not to exceed 4 g/d |
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| Contraindications | Documented hypersensitivity |
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| Interactions | Coadministration with cyclosporine may increase CNS adverse effects of both agents; coadministration with ganciclovir may result in generalized seizures |
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| Pregnancy | C - Safety for use during pregnancy has not been established.
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| Precautions | Adjust dose in renal insufficiency |
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| Drug Name | Ampicillin and sulbactam (Unasyn) |
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| Description | Drug combination of beta-lactamase inhibitor with ampicillin. Covers skin, enteric flora, and anaerobes. Not ideal for nosocomial pathogens. |
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| Adult Dose | 1.5 (1 g ampicillin + 0.5 g sulbactam) to 3 g (2 g ampicillin + 1 g sulbactam) IV/IM q6-8h; not to exceed 4 g/d sulbactam or 8 g/d ampicillin |
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| Pediatric Dose | <3 months: Not established
3 months to 12 years: 100-200 mg ampicillin/kg/d (150-300 mg Unasyn) IV divided q6h
>12 years: Administer as in adults |
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| Contraindications | Documented hypersensitivity |
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| Interactions | Probenecid and disulfiram elevate ampicillin levels; allopurinol decreases ampicillin effects and has additive effects on ampicillin rash; may decrease effects of PO contraceptives |
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| Pregnancy | B - Usually safe but benefits must outweigh the risks.
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| Precautions | Adjust dose in renal failure; evaluate rash and differentiate from hypersensitivity reaction |
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| Drug Name | Piperacillin and Tazobactam sodium (Zosyn) |
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| Description | Antipseudomonal penicillin plus beta-lactamase inhibitor. Inhibits biosynthesis of cell wall mucopeptide and is effective during stage of active multiplication. |
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| Adult Dose | 3/0.375 g (piperacillin 3 g and tazobactam 0.375 g) IV q6h for 7-10 d |
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| Pediatric Dose | <12 years: Not established
>12 years: Administer as in adults |
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| Contraindications | Documented hypersensitivity |
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| Interactions | Tetracyclines may decrease effects of ticarcillin; high concentrations of ticarcillin may physically inactivate aminoglycosides if administered in same IV line; effects when administered concurrent with aminoglycosides are synergistic; probenecid may increase penicillin levels |
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| Pregnancy | B - Usually safe but benefits must outweigh the risks.
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| Precautions | Perform CBCs prior to initiation of therapy and at least weekly during therapy; monitor for liver function abnormalities by measuring AST and ALT during therapy; exercise caution in patients diagnosed with hepatic insufficiencies; perform UA, BUN, and creatinine determinations during therapy and adjust dose if values become elevated; monitor blood levels to avoid possible neurotoxic reactions |
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| Drug Name | Clindamycin (Cleocin) |
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| Description | Lincosamide for treatment of serious skin and soft tissue staphylococcal infections. Also effective against aerobic and anaerobic streptococci (except enterococci). Inhibits bacterial growth, possibly by blocking dissociation of peptidyl t-RNA from ribosomes causing RNA-dependent protein synthesis to arrest. |
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| Adult Dose | 600-1200 mg/d IV/IM divided q6-8h depending on degree of infection |
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| Pediatric Dose | 20-40 mg/kg/d IV/IM divided tid/qid
Severe infections: May increase dose to 16-20 mg/kg/d IV/IM divided tid/qid |
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| Contraindications | Documented hypersensitivity; regional enteritis, ulcerative colitis, hepatic impairment, antibiotic-associated colitis |
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| Interactions | Increases duration of neuromuscular blockade induced by tubocurarine and pancuronium; erythromycin may antagonize effects of clindamycin; antidiarrheals may delay absorption of clindamycin |
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| Pregnancy | B - Usually safe but benefits must outweigh the risks.
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| Precautions | Adjust dose in severe hepatic dysfunction; no adjustment necessary in renal insufficiency; associated with severe and possibly fatal colitis |
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| Drug Name | Cefotaxime (Claforan) |
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| Description | For septicemia and treatment of gynecologic infections caused by susceptible organisms. Arrests bacterial cell wall synthesis, which in turn inhibits bacterial growth. |
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| Adult Dose | Moderate to severe infections: 1-2 g IV/IM q6-8h
Life-threatening infections: 1-2 g IV/IM q4h |
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| Pediatric Dose | <12 years: Not established
>12 years: Administer as in adults |
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| Contraindications | Documented hypersensitivity |
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| Interactions | Probenecid may increase cefotaxime levels; coadministration with furosemide and aminoglycosides may increase nephrotoxicity |
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| Pregnancy | B - Usually safe but benefits must outweigh the risks.
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| Precautions | Adjust dose in severe renal impairment; has been associated with severe colitis |
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| Drug Name | Ceftriaxone (Rocephin) |
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| Description | Third-generation cephalosporin with broad-spectrum gram-negative activity; lower efficacy against gram-positive organisms; higher efficacy against resistant organisms. Arrests bacterial growth by binding to 1 or more penicillin-binding proteins. |
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| Adult Dose | 1-2 g IV qd or divided bid depending on type and severity of the infection; not to exceed 4 g/d |
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| Pediatric Dose | >12 years: 50-75 mg/kg/d IV divided q12h; not to exceed 2 g/d |
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| Contraindications | Documented hypersensitivity |
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| Interactions | Probenecid may increase ceftriaxone levels; coadministration with ethacrynic acid, furosemide, and aminoglycosides may increase nephrotoxicity |
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| Pregnancy | B - Usually safe but benefits must outweigh the risks.
|
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| Precautions | Adjust dose in renal impairment; caution in breastfeeding women and allergy to penicillin |
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Drug Category: Synthetic posterior pituitary hormones
When D&C is not immediately available, these hormones are used to induce contractions to help evacuate retained products of conception from the uterus.
| Drug Name | Oxytocin (Pitocin, Syntocinon) |
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| Description | Produces rhythmic uterine contractions and can stimulate the gravid uterus, as well as vasopressive and antidiuretic effects. Also can control postpartum bleeding or hemorrhage. |
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| Adult Dose | 10-40 U IV in 1000 mL of IV fluid at a rate to control uterine atony |
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| Pediatric Dose | <12 years: Not established
>12 years: Administer as in adults |
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| Contraindications | Documented hypersensitivity; pregnant patients with severe toxemia, unfavorable fetal positions, and a contracting uterus with hypertonic or hyperactive patterns; labor in which vaginal delivery should be avoided (eg, invasive cervical carcinoma, cord presentation or prolapse, active herpes genitalis, total placenta previa, and vasa previa) |
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| Interactions | Pressor effect of sympathomimetics may increase when used concomitantly with oxytocic drugs, causing postpartum hypertension |
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| Pregnancy | X - Contraindicated in pregnancy
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| Precautions | A uterus that is overstimulated can be hazardous to both mother and fetus; hypertonic contractions can occur in a patient whose uterus is hypersensitive to oxytocin, regardless of whether oxytocin was administered appropriately; has intrinsic antidiuretic effect that when administered by continuous infusion and patient is receiving PO fluids, can cause water intoxication |
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Further Inpatient Care
- Perform a prompt evacuation of retained products of conception from the uterus.
- Administer aggressive antibiotic therapy.
- Monitor temperature, vaginal discharge, and bleeding.
Deterrence/Prevention
- Contraception to prevent unwanted pregnancies
- Safe and legal abortions
- Easy access to prenatal care
- Prompt diagnosis of septic abortion
- Timely treatment with IV antibiotics
- Prompt evacuation of retained tissue from the uterus
Complications
- Pelvic inflammatory disease
- Peritonitis
- Hemorrhage
- Sepsis
- Septic shock
- Inferior vena cava thrombosis
Patient Education
Medical/Legal Pitfalls
- Failure to obtain information about recent termination of pregnancy may lead to a wrong diagnosis or delayed/inappropriate treatment.
- Failure to promptly administer broad-spectrum antibiotic therapy may result in complications, including sepsis and septic shock.
- Failure to evacuate retained products of conception from the uterus leads to treatment failure and possible complications.
- Failure to diagnose uterine perforation may lead to litigation.
- Failure to diagnose bowel injury may lead to litigation.
- Cates W, Rochat RW, Grimes DA, Tyler CW Jr. Legalized abortion: effect on national trends of maternal and abortion-related mortality (1940 through 1976). Am J Obstet Gynecol. Sep 15 1978;132(2):211-4. [Medline].
- CherpesTL, Kusne S, Hillier SL. Haemophilus influenzae septic abortion. Infec Dis Obstet Gynecol. 2002;10(3):161-4. [Medline].
- Finkielman JD, De Feo FD, Heller PG, Afessa B. The clinical course of patients with septic abortion admitted to an intensive care unit. Intensive Care Med. Jun 2004;30(6):1097-102. [Medline].
- Finkielman JD, De Feo FD, Heller PG. The clinical course of patients with septic abortion admitted to an intensive care unit. Intensive Care Med. 2004;Jun;30(6):1097-102:[Medline].
- Jewett JF. Septic induced abortion. N Engl J Med. Oct 4 1973;289(14):748-9. [Medline].
- Kollef MH, Schuster DP. The acute respiratory distress syndrome. N Engl J Med. Jan 5 1995;332(1):27-37. [Medline].
- Rana A, Pradhan N, Gurung G, Singh M. Induced septic abortion: a major factor in maternal mortality and morbidity. J Obstet Gynaecol Res. Feb 2004;30(1):3-8. [Medline].
- Rochelson B, Scher L, Warshawsky R, Simon D. Use of a temporary vena cava filter in a woman with septic abortion and inferior vena cava thrombosis. A case report. J Reprod Med. Jul 2003;48(7):557-9. [Medline].
- Scott JR. Early pregnancy loss (septic abortion). In: Danforth's Obstetric and Gynecology. Lippincott-Raven Publishers;1994:179.
- Stevenson MM, Radcliffe KW. Preventing pelvic infection after abortion. Int J STD AIDS. Sep-Oct 1995;6(5):305-12. [Medline].
- Stubblefield PG, Grimes DA. Septic abortion. N Engl J Med. Aug 4 1994;331(5):310-4. [Medline].
Abortion, Septic excerpt Article Last Updated: Aug 29, 2006
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