Management of septic chemical abortion with renal failure. Use of a conservative regimen

Acute kidney injury complicating septic unsafe abortion: clinical course and treatment outcomes of 44 cases

AIM

 The aim of this study was to present the clinical course and treatment outcomes of patients with acute kidney injury (AKI) after septic unsafe abortion.

MATERIAL AND METHODS

Medical records of patients with AKI after septic unsafe abortion admitted at Khon Kaen Hospital between January 2003 and December 2009 were reviewed.

RESULTS

Forty-four patients with an average age of 24.3 years were included and 25% were teenage girls. The most common method of induced abortion was transvaginal chemical injection (81.8%). One patient had a hysterectomy due to severe peritonitis and sepsis that was not responsive to medical treatment. AKI developed on day 4.5 ± 3.6 with the range of onset 1-14 days after induced abortion. Oliguric AKI was present in 70.4% of patients with the mean duration of oliguria of 7.4 ± 5 days. Seventeen patients required dialysis. The mortality rate was 9%. The average duration of recovery from AKI was 24.8 ± 16.6 days.

CONCLUSIONS

  Conservative treatment of AKI-related septic unsafe abortion was dialysis without hysterectomy. The treatment results were minimal morbidity and mortality. Conservative management may be a better alternative to hysterectomy for the treatment of septic unsafe abortion with AKI. However the current study was a retrospective study, and we were not able to obtain certain follow-up data, such as fertility outcomes after recovery. Therefore, further study of these issues should be considered.

The clinical course of patients with septic abortion admitted to an intensive care unit

OBJECTIVE

The purpose of this study was to describe the clinical course, complications, and outcome of patients with septic abortion admitted to the intensive care unit (ICU).

DESIGN, SETTING, AND PATIENTS

In this retrospective study, the records of 63 patients with septic abortion admitted to the ICU of a university hospital in Argentina between 1985 and 1995 were reviewed.

RESULTS

The mean age of the patients was 28.5 years, and 33% had had previous abortions. The mean gestational age was 10.5 weeks. The first ICU day Acute Physiology and Chronic Health Evaluation (APACHE) II mean score was 13.9. Acute renal failure developed in 73% (46 of 63) of the patients, disseminated intravascular coagulation (DIC) in 31% (15 of 49), and septic shock in 32% (20 of 63). Blood cultures were positive in 24% (15 of 62). Twelve patients died (19%). Eight of the deaths occurred during the first 48 h of the ICU admission. Compared with survivors, non-survivors had higher median number of organ failures (1.0 vs 4.0, p<0.0001), mean first ICU day SOFA scores (6.6 vs 10.0, p=0.0059), and mean APACHE II scores (12.7 vs 20.2, p=0.0003), and were more likely to have septic shock (18 vs 92%, p<0.0001), and receive dopamine (37 vs 83%, p=0.0040), mechanical ventilation (8 vs 83%, p<0.0001), and pulmonary artery catheter (8 vs 41%, p=0.0026).

CONCLUSIONS

Although it is an avoidable complication, septic abortion requiring admission to the ICU is associated with high morbidity and mortality.

Acute renal failure in pregnancy

Acute renal failure (ARF) has become a very rare complication of pregnancy. This results from the virtual disappearance of septic abortion ARF and from the improvement of prenatal care, including the prevention of volume contraction which is mainly due to uterine haemorrhage, early diagnosis, and treatment of other classic maternal complications such as pre-eclampsia and acute pyelonephritis. The incidence of bilateral renal cortical necrosis has also been declining during the last decade. Acute fatty liver, a potentially fatal disease, is often complicated by ARF. Early recognition of this disorder, with prompt termination of pregnancy and intensive supportive therapy, can reduce fetal and maternal mortality rate. The syndrome of idiopathic postpartum renal failure is also associated with a high morbidity and mortality. Beyond supportive treatment, including haemodialysis or peritoneal dialysis and the use of potent antihypertensive drugs to control blood pressure and blood transfusion if necessary, specific therapy as plasma infusion, plasma exchange and antiplatelet drugs may be of value. Both peritoneal dialysis and haemodialysis may be used in gravidas with ARF. Early 'prophylactic' dialysis should be applied to pregnant women. Careful monitoring of fluid balance and anticoagulation is necessary during dialysis.

Septic shock with renal failure after chorionic villus sampling

A report of septic shock and renal failure after a chorionic villus sampling is presented. Uterine evacuation, antibiotics, and vasopressor therapy were unsuccessful in reversing hypotension, coagulopathy, and anuria. The patient's condition improved only after exploratory laparotomy and removal of the uterus, ovaries, and fallopian tubes. The incidence of such serious complications must be determined.

Conservative vs. surgical management of septic abortion with renal failure

The role of surgery in the management of postabortum renal failure complicated with extensive uterine sepsis, perforation or peritonitis is controversial. This study compares the course and final outcome of 14 patients (66.6%) conservatively managed with appropriate antibiotics, fluid or blood replacement and dialysis, with seven patients (33.3%) for whom hysterectomy or laparotomy was undertaken in addition. Whereas all 14 patients treated conservatively died as the result of uncontrolled septicemia, three of the seven surgical patients recovered completely. Extensive necrosis with perforation of the uterine wall was confirmed either at laparotomy or at autopsy in all 21 women. To reduce mortality, the authors recommend early surgical intervention for patients suffering from postabortum renal failure complicated with uterine sepsis or perforation.

The management of septic abortion in an intensive care unit

The value of ICU treatment in the management of septic abortion has been assessed. Of patients subjected to hysterectomy, the mortality is now 20%, as opposed to 37% prior to the advent of ICU. It would therefore appear that these patients can benefit from intensive nursing and medical attention.