Induced abortion

Abortion is common. Data on abortion rates are inexact but can be used to explore trends. Globally, the estimated rate in the period 2010-2014 was 35 abortions per 1000 women (aged 15-44 years), five points less than the rate of 40 for the period 1990-1994. Abortion laws vary around the world but are generally more restrictive in developing countries. Restrictive laws do not necessarily deter women from seeking abortion but often lead to unsafe practice with significant mortality and morbidity. While a legal framework for abortion is a prerequisite for availability, many laws, which are not evidence based, restrict availability and delay access. Abortion should be available in the interests of public health and any legal framework should be as permissive as possible in order to promote access. In the absence of legal access, harm reduction strategies are needed to reduce abortion-related mortality and morbidity. Abortion can be performed surgically (in the first trimester, by manual or electric vacuum aspiration) or with medication: both are safe and effective. Cervical priming facilitates surgery and reduces the risk of incomplete abortion. Diagnosis of incomplete abortion should be made on clinical grounds, not by ultrasound. Septic abortion is a common cause of maternal death almost always following unsafe abortion and thus largely preventable. While routine follow-up after abortion is unnecessary, all women should be offered a contraceptive method immediately after the abortion. This, together with improved education and other interventions, may succeed in reducing unintended pregnancy.

Study on Clinical Presentation and Outcome of Septic Abortion and Its Relationship with Person Inducing Abortion

Abortion is a global problem. Maternal mortality and morbidity is still high due to uncontrolled abortion mainly induced abortion which may turn to septic abortion. A total of 50 cases of septic abortion cases admitted in Dhaka Medical College Hospital were included in this study. This cross sectional study was designed to find out the clinical presentation and outcome of septic abortion from January 2010 to January 2011. Out of 50 cases of septic abortion admitted where 44(88%) were induced abortion. Majority of the cases were parous (2-3 parity 32%; 4-6 parity 38%; and 6+ parity 4%) and housewives 42(84%), living with their husbands 49(98%), hailing from urban, semi urban and urban slums. Nineteen (38%) having no education and 21(42%) had primary education. Most of the women 20(45.45%) wanted no more child, decided to terminate pregnancy not to overburden their families or due to disturbed marital relationship. The termination of pregnancy was carried out in first trimester 20(40%) and between (13-16) weeks it was 17(34%). Complications of septic abortion still remain a lethal threat to the life and health of women. The death rate was found 6(12%). And the leading causes of death were generalized peritonitis with septicaemia 3(50%), septicaemia with renal failure 2(33.30%), septic abortion with Disseminated Intravascular Coagulation 1(16.70%). Effective and widespread contraceptive use and continuing health and sex education remain pivotal if the incidence of septic abortion and their complications are to be reduced.

Streptococcus G leading to septic abortion and multiple organ failure

The authors report a patient admitted at 12 weeks of pregnancy with an acute infectious syndrome, leading to abortion, sepsis, and multiple organ failure. Admission to intensive care unit (ICU) was needed after curettage for incomplete abortion complicated by uterine atony, hemorrhage, and septic shock. The patient had multiple organ failure and required non-invasive ventilation. Hemoculture showed streptococcus G bacteremia. She had no evidence of concurrent infection, mainly genital or urinary, except amygdalitis few days before. Hematogenous spread to the gestational sac could have possibly been the cause of her sepsis. Streptococcus G infection during pregnancy can lead to severe consequences.

Comparison of condition specific indicators among illegal induced abortion: septic and non-septic abortion in Songkla Center Hospital

OBJECTIVE

Determine the clinical indications of illegal induced abortion, comparison between septic and non-septic abortion.

MATERIAL AND METHOD

The present retrospective descriptive study was conducted among pregnant women who were admitted in the hospital with the illegal induced abortion. The demographic data, gestational age, the method used, and personnel performing were gathered, as well as symptomatology, basic laboratory, condition progression, and medical and surgical intervention.

RESULTS

There were 92 patients with illegal induced abortion between March 2009 and December 2010. The three main induced methods for termination of pregnancy was vaginal suppository, likely to be misoprostol-a synthetic prostaglandin E, analog (43.5%), oral Thai herbal medicine (19.6%) and combined medication (16.3%), respectively. Of septic/non-septic abortion, the first visit body temperature of 38.0 degrees Celsius or more (74.1/12.3%), heart rate of 100 per minutes or more (74.1/12.3%), fever index 3 degree-hours or more in the first 24 hours (81.5/12.3%) and fever index 5 degree-hours or more in the first 24 hours (59.3/1.5%), were statistically significant (all p-values of < 0.001). Overall, the most common type of termination of induced abortion was incomplete abortion 68 in 92 cases (73.9%).

CONCLUSION

The first visit body temperature of 38.0 degrees C or more, heart rate of 100 per minutes or more and fever index of 3 and 5 degree-hours, are clinically helpful in the early diagnosis and treatment of septic abortion.

Septic abortion: a 5-year experience at Siriraj Hospital

OBJECTIVE

To report characteristics of the patients with septic abortion between 2006 and 2010.

MATERIAL AND METHOD

The present retrospective study was done by reviewing the medical records of the women who were admitted to Siriraj Hospital between 2006 and 2010 with the diagnosis of septic abortion.

RESULTS

Eighty-three women were admitted to Siriraj Hospital and diagnosed with septic abortion. The mean age was 25.1 years (range 14 to 40 years) and the mean gestational age was 11.3 weeks (range 6 to 24 weeks). Fifty percent of them had a history of induced abortion and 65% came with an incomplete abortion. The principal presenting symptom was abnormal uterine bleeding. Insertion of vaginal tablets appeared to be the most commonly used method of induced abortion. Ampicillin and gentamicin plus metronidazole were the mainstay empirical antibiotics. Length of hospital stay ranged from 2 to 24 days. After the clinical improvement, oral pill was the most popular contraceptive method.

CONCLUSION

Septic abortion remains a big issue in Thai society. To mitigate the problem, sex education, particularly emphases on contraception, should be encouraged.

[Acute toxicity by methotrexate used for abortion purpose. Case report]

We report the case of a 16 years old female patient, with a pregnancy history of 11.4 weeks by ultrasound and intrauterine fetal death. In a private clinic were prescribed methotrexate 500 mg intramuscular single dose, and vaginal misoprostol. She had a clinical feature of five days of evolution characterized by fever of 39 degrees C, nausea, general attack and vomiting. The initial diagnosis was severe sepsis secondary to septic abortion, oral candidiasis and acute poisoning by methotrexate. After that, she was referred to the Instituto Nacional de Perinatologia, where stayed with fever for four days, and was managed with hydration, antibiotics, folinic acid and alkalizing. Her recovery was gradual. She was discharged after 12 days with significant clinical improvement. The literature review describes that the use of methotrexate for abortion purpose with therapeutic-dose presents a similar adverse effects to those found in our patient, however there are no case reports that describe the use of this drug in macrodosis for the same purpose, and their cytotoxic effects. We present this case because the patient used a macrodosis of this antimetabolite and due to the premature and empirical management with folinic acid, joined with alkalinization of urine, is the ideal treatment and as it is illustrated in our case.

Clinical characteristics and outcomes of obstetric patients requiring ICU admission

OBJECTIVES

To review a series of critically ill obstetric patients admitted to our ICU to assess the spectrum of disease, required interventions, and fetal/maternal mortality, and to identify conditions associated with maternal death.

DESIGN

Retrospective cohort.

SETTING

Medical-surgical ICU in a university-affiliated hospital.

PATIENTS

Pregnant/postpartum admissions between January 1, 1998, and September 30, 2005.

INTERVENTIONS

None.

MEASUREMENTS AND RESULTS

We studied 161 patients (age, 28 +/- 9 years; mean gestational age, 29 +/- 9 weeks) [mean +/- SD], constituting 10% of 1,571 hospital admissions. APACHE (acute physiology and chronic health evaluation) II score was 14 +/- 8, with 24% predicted mortality; sequential organ failure assessment score was 5 +/- 3; and therapeutic intervention scoring system at 24 h was 25 +/- 9. Forty-one percent of patients required mechanical ventilation (MV). ARDS, shock, and organ dysfunction were present in 19%, 25%, and 48% of patients, respectively. Most patients (63%) were admitted postpartum, and 74% of admissions were of obstetric cause. Hypertensive disease (40%), major hemorrhage (16%), septic abortion (12%), and nonobstetric sepsis (10%) were the principal diagnoses. Maternal mortality was 11%, with multiple organ dysfunction syndrome (44%) and intracranial hemorrhage (39%) as main causes. There were no differences in death rate in patients admitted for obstetric and nonobstetric causes. Fetal mortality was 32%. Only 30% of patients received antenatal care, which was more frequent in survivors (33% vs 6% nonsurvivors, p = 0.014).

CONCLUSIONS

Although ARDS, organ failures, shock, and use of MV were extremely frequent in this population, maternal mortality remains within an acceptable range. APACHE II overpredicted mortality in these patients. Septic abortion is still an important modifiable cause of mortality. Efforts should concentrate in increasing antenatal care, which was clearly underprovided in these patients.

Lymphangioma of the fallopian tube--a case report

Lymphangioma of the fallopian tube is very rare. Only one such case has been reported. A 30-years-old female with lymphangioma of the left fallopian tube is described here. She presented with fever, vaginal bleeding and foul smelling discharge. A mass was felt in left fornix. On exploratory laparotomy, a left tubo-ovarian mass adherent to the surrounding structures was seen. Clinical diagnosis was septic abortion with adhesions. Left-sided partial tubectomy was performed. Histology of the left tube revealed large dilated channels containing lymph in the submucosa. Lymphocytes were also seen in some channels. Histogenesis of lymphangioma remains uncertain. Presence of adhesions in this case suggests a reactive origin. Histopathology is confirmatory for diagnosis.

[Current epidemiologic features of septic abortion]

BACKGROUND

This article deals with the current epidemiological features of septic abortion.

METHODS

Forty-two of 431 abortions (9,74%) were diagnosed as septic abortions during 1998 at the I and II Institute of Obstetrics and Gynecology, University of Rome La Sapienza , and are retrospectively analyzed.

RESULTS

Thirty-four women (81%) came from an EEC country, whereas 8 (19%) from a developing country. Their mean age was 31,4 years (range: 18-43 years). Eighteen patients (43%) were nulliparous; 24 (57%) multiparous; 14 (33%) had previous abortions, none had previous septic abortions. Among risk factors, premature rupture of membranes was found in 5 cases (12%); whereas amniocentesis, HIV positivity, diabetes, positive urine culture and illegal pregnancy termination procedures were found in 5 further cases. No risk factors were found in 76% of patients.

CONCLUSIONS

It is observed that, due to medical-scientific advances, previously unknown risk factors have emerged during the last three decades in Western Countries, such as invasive procedures of prenatal diagnosis, IUD contraception and AIDS immunodepression. However, other previously frequent risk factors, such as sepsis from illegal abortion, may emerge again in Countries where abortion is legal (such as Italy), due to massive immigration of clandestine women from developing Countries.

[Procalcitonin as monocytic marker for early diagnosis in septic abortion]

BACKGROUND

In search of sensitive and specific markers of systemic infection procalcitonin (PCT) recently was promoted to the focus of clinical research. Little is known about the biology of PCT and until now no data have been presented about clinical importance of PCT in obstetric patients.

PATIENT AND METHODS

Daily PCT values in a 17 year old patient with septic abortion were compared with established markers of systemic inflammation. Cultivated monocytes were analyzed by the means of indirect immunofluorescence for intracellular distribution of PCT. Additionally, PCT release into culture medium was examined.

RESULTS

PCT values in comparison with established inflammation markers was demonstrated in the patient with septic abortion. Indirect immunofluorescence studies revealed the presence of PCT within monocytes. In the supernatants of monocyte cultures PCT was detectable under control conditions. Stimulation with lipopolysaccharide resulted in the increased PCT concentrations both in the supernatants of healthy and patient monocyte cultures.

CONCLUSIONS

In the given patient PCT was superior to other inflammation markers with regard to early and progression diagnosis. Peripheral blood monocytes appear to be a potential site of inflammation-induced PCT production. For the first time intracellular distribution pattern and release of PCT from human monocytes was described.

DISCUSSION

Based on the presented data broad clinical studies devoted to PCT evaluation in obstetric patients seem to be promising. As till now the interpretation of increased PCT values depended on empirical knowledge, extensive studies of the potential production site as well as its biological significance should be performed, too.

Comparison of five tests for the detection of antibodies against chlamydial (enzootic) abortion of ewes

Five tests for antibodies against chlamydial (enzootic) abortion of ewes were compared using 255 sera from experimentally (group 1) or naturally (group 2) infected animals, flocks free of the disease (group 3) and individual animals testing positively by the complement fixation test but from flocks with no evidence of chlamydial abortion (group 4). Sera from five specific pathogen-free lambs vaccinated with two different subtypes of Chlamydia pecorum were also included (group 5). All tests used some form of processed culture of C psitiaci as antigen. Specificities, established with group 3 and 4 sera, ranged between 96 per cent (ELISA using lipopolysaccharide antigen) and 59 per cent (Immunocomb). Reactions with group 5 sera suggested that the cause of false positive results in the field might be cross-reactive antibodies against the arthritogenic subtype of C pecorum. Sensitivities, established with groups 1 and 2 sera, ranged between 81 per cent (Immunocomb) and 51 per cent (ELISA using solubilised protein antigen). The minimum sample sizes required to be 95 per cent certain of detecting at least five seropositives in two infected flocks (combined data) were 15 to 48, dependent on the test applied. The Western blot test, applied to a proportion of samples, yielded no false positives with group 3 sera but 31.7 per cent with group 4 sera. Thus, none of the tests in this comparison emerged as sufficiently satisfactory in all respects, suggesting that further improvements in chlamydial serology must come through the use of non-native antigens or in the form of a competitive ELISA.

[Septic abortion in Campylobacter jejuni infection]

Case report of a 24 year old woman II G/I P with enterocolitis and septicaemia caused by Campylobacter jejuni (C.) in the following time abortion at 16 weeks of gestation. Diagnostics, therapy, review of literature.

[Current concepts in the pathogenesis and treatment of abortion and septic shock I. The epidemiology, pathogenesis and management of septic abortion]

In view of the illegal status induced abortion, it is difficult to determine the degree to which it is practiced. In our country there are a great inconsistency in the statistics on the number of abortions and the number of maternal deaths due to this cause. The principal complication of the illegal induced abortion is the septic abortion, with an uncontrolled bacterial infection and systemic complications that dominate the clinical picture. The mortality of the septic abortion is elevated, in the majority of cases due to septic shock. The treatment consist on antimicrobial agents and early surgery. A reduction on the number of illegal abortions will decrease significantly the number of septic abortion's cases.

Fetal listeriosis during the second trimester of gestation

Listeriosis is common and is implicated in about 3% of second-term abortions examined in our laboratory. Maternal fever was followed rapidly in all instances by the expulsion of a nonmacerated fetus. Chorioamnionitis was always present and was associated with placental microabscesses. Leukocytic infiltrates were frequent in fetal tissues, being present in adrenal, lung, and skin. Listeria monocytogenes was isolated from 8 of the 205 abortions that had microbiological cultures (3.9%). The clinical features and morphological lesions were so characteristic that the diagnosis of listeriosis could be made in 5 of the 217 fixed abortuses received during the same period, but without culture. In contrast to the third trimester of pregnancy, there were no inflammatory lesions in the central nervous system in our small series.

Chronic myeloid leukemia presenting as a gynecological emergency

An unusual case of chronic myeloid leukemia presenting to the gynecological unit as a case of septic abortion is presented. Though history and clinical examination suggested the possibility of double pathology of septic abortion and chronic myeloid leukemia, histology of the products removed from the uterus showed it to be leukemic deposits. The diagnosis of leukemia was confirmed by marrow aspiration (trephine biopsy). Careful clinical examination and systematic investigation helped in diagnosing the pathology and to treat her appropriately.

[Proteus septicemias. Apropos of 4 cases]

The authors record four cases of septicemia caused by Proteus, observed at the "Hôpital Girard et Robic" resuscitation department, in Tananarive, Madagascar. The patients were young and free from visceral disorders. The first case was a post-abortum etiology with a myocardial clinical picture. The second case also was a post-abortum etiology. The course led to the septic shock and to the death. The starting point of the third case was the urinary system, following upon the removal of an urinary obstruction due to post-operative anuresis. In the fourth case, the focus was urinary with a pulmonary clinical picture. The course led to the septic shock and to the death. In all instances, the germ showed sensitivity to amikacin and to the third-generation cephalosporins. The clinical course that led to the septic shock had deeply entailed the prognosis of these septicemias.

Diagnostic studies of the fetus, placenta and maternal blood from 265 bovine abortions

During 1981, the fetus, placenta and maternal serum were received from each of 265 bovine abortions. These specimens were examined using histopathological, histochemical, bacteriological, mycological, endocrinological, immunological, serological and virological techniques. The cause of abortion was identified in 98 (37%) cases. Of these diagnosed abortions 27 (28%) were due to infection with fungi, 17 (17%) to Salmonella spp, 11 (11%) to Campylobacter fetus and 10 (10%) to Corynebacterium pyogenes infection. Of the remaining 33 (34%) diagnosed abortions 8 were due to Leptospira sp, 5 due to protozoan (probably Sarcocystis) encephalitis and 20 due to miscellaneous bacterial infections (including Brucella abortus) and fetal deformities. Bovine virus diarrhoea virus was isolated in 5 (2%) abortions, however the significance of the isolations was not known. Infectious bovine rhinotracheitis virus and chlamydia were not identified as causal agents in any abortion. In 18 (7%) abortions no definite etiologic agent was identified despite pathological findings suggestive of infection. Fetal heart blood serology and immunoglobulin values were not reliable indicators of infectious abortion. Of the remaining 149 (56%) abortions, 17% had high maternal serum cortisol levels and twin fetuses occurred in 9%.

Behavioral factors contributing to abortion deaths: a new approach to mortality studies

One hundred six women were reported to have died from abortions (55 legal, 10 illegal, and 41 spontaneous) in the United States from 1975 through 1977. In reviewing these deaths, the authors developed a new approach to mortality studies. A catalogue was compiled of behavioral factors (including actions by physicians, patients, communities, and institutions) that in the authors' judgment increased the risk of death from abortion. The proportion of abortion deaths to which each behavioral risk factor contributed was determined. Of the 199 different behavioral factors, 5 contributed to more than 10% of legal abortion deaths, 5 to more than 10% of illegal abortion deaths, and 3 to more than 10% of spontaneous abortion deaths. The most frequent factors involved were delay in obtaining a legal abortion until 13 weeks' gestation or later, incomplete abortion, and inappropriate choice of antibiotics for septic abortion. Assessing the proportion of abortion deaths to which each factor contributed can help identify which factors deserve priority in prevention.

[Diagnosis of septic abortion in dairy cows]

During a two year period, March 1977 to April 1979, a total of 92 bovine abortions were studied. The cause of abortion was determined in 34.8% of the cases examined. Opportunistic bacteria, the most commonly diagnosed cause of abortion, accounted for 31.2% of the cases. Leptospirosis was associated with 28.1% of the abortions, infectious bovine rhinotracheitis and fungi in respectively 15.7%, bovine viral diarrhea in 6.2%. A congenital abnormality accounted for one case (3.1%). In 23 cases (25%), there was no definitive diagnosis, in spite of evidence of experience with pathogen or suggestive findings of pathology, but insufficient evidence to warrant diagnosis. No findings were recorded in 35.8% of the (possibly noninfectious) cases and in only four cases (4.4%), specimens were unsatisfactory for examination.

Embryonal rhabdomyosarcoma. A case report

A patient with embryonal rhabdomyosarcoma, who presented with septic criminal abortion, is discussed. The fact that the correct diagnosis was obscured by the unusual sequence of events is commented upon, and the need for critical evaluation of apparently clear-cut cases is demonstrated.