Serious infection associated with induced abortion in the United States

Infections caused by Clostridium perfringens and Paeniclostridium sordellii after unsafe abortion

After the legalisation of abortion in the USA in 1973, the risk of infectious morbidity and mortality from this procedure notably decreased. With increasingly restrictive legislation targeting access to safe abortion services, reviewing infectious complications of unsafe pregnancy termination is crucial, particularly the diagnosis and management of life-threatening clostridial (and related anaerobic bacterial) infections that can complicate unsafe abortion. This Review deals with two especially devastating infections that are well-documented causes of septic abortion: the anaerobic, spore-forming pathogens Clostridium perfringens and Paeniclostridium sordellii. We seek to familiarise the reader with these bacteria, the clinical syndromes they can cause (with a focus on toxic shock syndrome), and provide a review of diagnosis and treatment options.

Clostridium Perfringens Bacteremia with Acute Hemolytic Anemia in the Setting of Endometrial Malignancy

Acute intravascular hemolysis is a rare and often lethal complication of Clostridium perfringens septicemia.Clostridium perfringens is an anaerobic, gram-positive spore-forming rod which is commonly implicated in cases of food poisoning, gas gangrene, and severe hemolytic anemia in humans via the alpha-toxin (phospholipase C). We report an interesting and rare case of a 72-year-old woman who developed massive intravascular hemolysis secondary to C perfringens bacteremia in the setting of poorly differentiated high-grade endometrial malignancy.

Assessing the effectiveness of empiric antimicrobial regimens in cases of septic/infected abortions

INTRODUCTION

Infected abortion is a life-threatening condition that requires immediate surgical and medical interventions. We aimed to assess the common pathogens associated with infected abortion and to test the microbial coverage of various empiric antimicrobial regimens based on the bacteriological susceptibility results in women with infected abortions.

METHODS

A retrospective study in a single university-affiliated tertiary hospital. Electronic records were searched for clinical course, microbial characteristics, and antibiotic susceptibility of all patients diagnosed with an infected abortion. The effectiveness of five antibiotic regimens was analyzed according to bacteriological susceptibility results.

RESULTS

Overall, 84 patients were included in the study. The mean age of patients was 32.3(SD ± 5.8) years, and the median gestational age was 15 (IQR 8-19) weeks. Risk factors for infection were identified in 23 patients (27.3%), and included lack of medical insurance (n = 12), recent amniocentesis/chorionic villus sampling or fetal reduction due to multifetal pregnancies (n = 10). The most common pathogens isolated were Enterobacteriaceae (35%), Streptococci (31%), Staphylococci (9%) and Enterococci (9%). The combination of intravenous ampicillin, gentamicin and metronidazole showed significant superiority over all the other tested regimens according to the susceptibility test results. Piperacillin-tazobactam as an empiric single-agent drug of choice and provided a superior microbial coverage, with a coverage rate of 93.3%.

CONCLUSIONS

A combination of ampicillin, gentamicin, and metronidazole had a better spectrum of coverage as a first-line empiric choice for patients with infected abortion.

Development of medical termination of pregnancy: a review

The synthesis of mifepristone, an antiprogestin blocking the action of progesterone at the receptor level, started a new era of medical termination of pregnancy (MTOP). The initial results of MTOP with mifepristone alone were disappointing; however, mifepristone can sensitise the myometrium to the action of prostaglandins. Clinical trials have shown that the sequential administration of mifepristone followed 1-2 days later by a prostaglandin analogue is a safe, effective, and acceptable method for MTOP. This article will review the events and challenges leading to the development of the current evidence-based and yet off-label regimen for first-trimester MTOP.

TWEETABLE ABSTRACT

This article reviews the events and challenges in the development of medical termination of pregnancy.

Medical Abortion

OBJECTIVE

This guideline reviews the evidence relating to the provision of first-trimester medical induced abortion, including patient eligibility, counselling, and consent; evidence-based regimens; and special considerations for clinicians providing medical abortion care.

INTENDED USERS

Gynaecologists, family physicians, registered nurses, midwives, residents, and other healthcare providers who currently or intend to provide pregnancy options counselling, medical abortion care, or family planning services.

TARGET POPULATION

Women with an unintended first trimester pregnancy.

EVIDENCE

Published literature was retrieved through searches of PubMed, MEDLINE, and Cochrane Library between July 2015 and November 2015 using appropriately controlled vocabulary (MeSH search terms: Induced Abortion, Medical Abortion, Mifepristone, Misoprostol, Methotrexate). Results were restricted to systematic reviews, randomized controlled trials, clinical trials, and observational studies published from June 1986 to November 2015 in English. Additionally, existing guidelines from other countries were consulted for review. A grey literature search was not required.

VALUES

The quality of evidence in this document was rated using the criteria described in the Report of the Canadian Task Force for Preventive Medicine rating scale (Table 1).

BENEFITS, HARMS AND/OR COSTS

Medical abortion is safe and effective. Complications from medical abortion are rare. Access and costs will be dependent on provincial and territorial funding for combination mifepristone/misoprostol and provider availability.

SUMMARY STATEMENTS

Introduction Pre-procedure care Medical abortion regimens Providing medical abortion Post-abortion care

RECOMMENDATIONS

Introduction Pre-procedure care Medical abortion regimens Providing medical abortion Post-abortion care.