2.5 the Parameters of Septic Abortion. m. Botes

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11 September 1971 S.A. JOURNAL OF OBSTETRICS AND GYNAECOLOGY 37

The Parameters of Septic Abortion *M. BaTES, M.B., CH.B., Department of Obstetrics and Gynaecology, H. F. Verwoerd Hospital, Pretoria

SUMMARYA retrospective analysis of 50 cases of septic incompleteabortion i s made. The clinical picture, v a g ~ l 1 a l discharge,bacteriologic cultures of the cer vix and uterine cavityand the histopathological picture of the uterine curette-ments are correlated. Certain conclusions and suggestionsbased on the results of this pro ject are made.S. Afr. J. Obstet. Gynaec., 9, 37 (1971).

When considering the problem of septic abortion, thefollowing questions come to mind: What is a septic abortion? How can a case of septic abort ion be identified? I fidentified, should it be treated by immediate evacuation,or by evacuat ion only after the patient is afebrile?Answers to these ques tions from the available literatureare difficult to obtain and are often contradictory.

The diagnosis of septic abortion-in a pregnant patientwith vaginal bleeding and pyrexia, and after excluding anextra-uterine source of infection-may be made in thepresence of one or more of the following signs and symptoms:'1. A history of criminal intervention. (Such information

can be obtained from about 30% of patients, but onlyaf ter the most diligent questioning.)2. Oral temperature lOOF or higher.3. Salmon-pink offensive uterine discharge.4. Symptoms of pelvic or generalized peritonitis.5. Leucocyte count of 15 DOO/mm' or more.How important is the elevated temperature? Most definitions a re based on the assumption that a raised temperatureis present. Davis' in his cl inical survey of 2665 cases ofabortion, found an elevation of temperature in 84%. Toprevent sequelae of septic abortion, early therapy is the

sine qua non of a favourable outcome. Does this thereforeimply that 84% of the abort ions admit ted mus t be treatedaggressively? I f not, what parameters should be employedto estabUsh the diagnosis?This study was based on the definition of Moritz andThompson,' viz.: A septic abortion is any abortion, eitherthreatened, imminent, incomplete or comple te in which theendometrial cavity and / or its contents are infected by anymeans. To evaluate the spread of infection, we groupedthe septic abortions in to 3 types: 1

Group I: Cases with infec tion l imited to the uterusalone.Group IT: Cases with extra-uterine spread of infection to parametrium and/or adnexa.Group Ill: Cases with pelvic or generalized peritonitis.These groupings were determined clinically. Group Iseptic abortion was diagnosed even in the absence ofpyrexia.

~ P a p e r presented at t he Inter im Congres s of th e South Af ri can Society ofObstetr icians and Gynaecologists (M.A.S.A.) . Bloemfontein. March 1970.

The purpose of the project was (i) to correlate bacterialcultures with the clinical classification and with specialreference to the offensive vaginal discharge; (ii) to determine whether there is a dominant clinical parameter; and(iii) to evaluate, after consideration of (i ) and (ii), whetherendotoxic shock can be prevented by prophylacti c t reat ment.

MATERIALS AND METHODSFor the purpose of this study, 50 cases of septic incompleteabortion were grouped according to the abovementionedclassification. The case histories, clinical dat a and laboratory findings were compiled and filed on a special questionnaire form for further correlation. In order to solve thequestion of possible criminal iJ11tervention, an effort wasmade to determine whethe r the pregnancy was desired.Marital status and history of previous pregnancies andabort ions were noted. If , after a direct question to thepat ient as to whether attempts had been made to terminatethe pregnancy, any doubt existed, the case was inc luded inthe criminal intervention group.

In order to obtain all clinical information, every patienton admission underwent a thorough general and vaginalexamination. When inserting 1he vaginal speculum nolubrication was used, and a swab was taken from the upperthird of the vagina and from the cervical canal. The cervixwas then cleaned with chlorhexadine, dried with sterilegauze, and a sterilized glass cannula was inserted throughthe cervical canal into the uterine cavity. A swab of theuterine contents was then taken through this cannula(Fig. 1). Both cervical and uterine swabs were cultu red

Fig. 1. Glass cannu la with throat swab.

within 3 hours , aerobical ly and anaerobically, and drugsensitivity tests were performed on all cultures. The timeinterva l between admiss ion and curettage was noted,and the products of concept ion were fixed in 4% formaldehyde. Histopathological examination was performed withspecial care to conf irm the diagnosis of pregnancy, i.e. thepresence of villi and decidua. The degree of degenerationof the products of conception were est imated as well asleucocyte infiltration and the number of bacterial colonies_


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38 S.A. TYDSKRIF VIR OBSTETRIE EN GINEKOLOOIE 11 September 1

Fig. 2 shows the correlation between the offensive vagid ischarge and the bacter io logical cul tures. In the cawhere infection was limited to the uterus (group I), o14% had offensive vaginal discharge, although 23% yieldpositive cervical cultures and 9% posit ive uterine cultur

of no growth, a lt hough they were imbedded within3-hour period. This matter is being investigated furtherThe uterine cavity cultures (T".hle IT) were also do

na ted by the pathogenic organism E. coli, either alonein combination. The high percentage of swabs resultingno growth, is what one would expect from the utercavity.

TABLE 11. UTERINE CAVITY SWAB CULTURES

IITypeoType 286

71

ype 157

43

33

23I I11

9I

PARAMETERS of I FECTIONoffensivevaginaldischarge

cervicalculture

E. coliE. coli + Aerobacter aerogenesProteus + Beta haemolytic streptococcusProteus vulgaris + E. coliAerobacter aerogenesProteus mirabilis + E. coliBeta haemolytic s ~ r e p t o c o c c u sNo growth

uterineculture

The results of the investigations presented here should beregarded as a preliminary report, as a l arger series is contemplated. According to the previously mentioned clinicalclassification, the 50 cases of septic incomplete abortionswere grouped as fol lows: 22 cases (44%) where tendernesswas confined to the uterus (group I); we had 21 cases(42%) where spread o f infection to parametrium and/or.adnexa was present (group H); and 7 cases (14%) withpelvic or generalized peritonitis (group IH).The per iod of t ime between commencement of abortion.and admission was noted, because of the commonly held

belief that the longer this interval, the greater the incidenceof septic abortion. In this series, however, there was nocorrelation, as the interval was 22 days in group I cases,.30 days in group Hand 21 days in g roup HI.The mean temperature on admission, was 989F in.group I, 101F i n g roup H, and 1024OF in group IH. Theincrease in temperature was therefore directly proportional

to the clinical spread of infection. In other words , group I.and group H septic abort ions fit into the definitions menti oned by o ther authors. These authors s tress pyrexia asbeing the most dominant clinical parameter, and they alsostress the point that the pa ti en t should be afebr ile be foredoing a vaginal evacuation. At H. F. Verwoerd Hospital,we do not accept elevated temperature as the only dominant clinical parameter, nor does the presence of elevatedtemperature usually prevent us from taking the patient totheatre for vaginal evacuation.

A further finding was that of t he cases wi th a his tory ofcriminal intervention 9(, were in group I, 57% in groupII , and 86% in group HI. This distribution confirms that incases with extra-ute rine spread of infection, there is astrong possibility that intervention has taken place.The bacteriological cultures of cervical swabs are shown

in Table I.

RESULTS

These 3 factors were expressed as mild, moderate or severe,according to degree.

From the above table it can be seen that the dominantorganism is E. coli, either alone or in combination withother organisms. A high percentage of swabs gave results

TABLE I. CE RVI CA L SWAB CULTURESE. coli (alone)E. coli + Aerobacter aerogenesCoag. pos. staph.Aerobacter aerogenesProteus mirabilis + Aerobacter aerogenesE. coli + Proteus vulgarisProteus + Beta haemolytic streptococcusProteus + E. coli + Beta haemolytic streptococcuslactobacillus + Doderlein's bacillusNo growth

92221112129

50

7110 20 30 40 50 60 70 80 90 10Percenrage

Fig. 2. Correlation of discharge with bacteriological cul-tures.

In the group 11 cases (extra-uterine spread of infectionparametrium or adnexa) the positive cervical and utericultures were less than the incidence of offensive vagindischarge. By comparison, the cases with peritonit is (grouHI) showed a very s tr ong correlation: 71 % offensive dicharge with 86% positive cervical cultures and 71 % positiuterine cultures.The histopathological results were unexpected. Thhistological basis for the diagnosis of infected products oconception is the presence of an infiltrate of acute inflam

matory cells. Fig. 3 shows the his tological p ic tu re of


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11 September 1971 S.A. JOURNAL OF OBSTETRICS AND GYNAECOLOGY 39

Fig. 6. Group n septic abort ion. Bacterial colony presentand no neutropbils-negative neutrophil response.

Fig. 7. Group III septic abortion with a negative neutrophilresponse.

Fig. 5. Group n septic abortion. Organisms present, witha negat ive neutrophil response.

Tabulating the histological findings in the different clinical types of septic abortion according to the leucocyte

t"

Fig. 4. Group ID septic abortion: histology.

case of spontaneous abort ion classified as group I, i.e.uterine tenderness and a normal temperature. The strikingfeatures are the extent of neutrophil leucocyte infiltration,the minimal degeneration of products of conception, andthe absence of organisms. Thi s finding has been termedthe positive neutrophil response.

Fig. 3. Group I septic abortion: histological picture.

Fig. 4 shows the histological picture of a patient fromgroup III who developed a temperature of I022F. Thereis minimal neutrophil infil tration, bacterial colonies arepresent and there is no degeneration of products of conception. This finding has been termed a negative neutrophil response. Figs 5 - 7 are lhe histological pictures ofgroup II and group ID septic abortions, which fur therillustrate this negahve response.

Fig. 8 is the histological picture of a group II septicabort ion showing, as expected, organisms plus a positiveneutrophil response--in other words, a neutrophil leucocyteinfiltration to combat the amount of organisms.


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40 S.A. TYDSKRIF VIR OBSTETRIE EN GINEKOLOGIE 11 September 1971

DISCUSSION

group I there is a 75% posllive and a 25% negative response. Group Il shows a 40% posit ive and a 60% negat ivresponse, while group III has a 30% posi tive and a 70%negative response. I t appears that the more overwhelmingthe infection, the less is the response of the body againsthis infection.

The presence of a salmon-pink offensive uterine dischargeas the resul t of an intra-uterine infection can be clearlyseen in the group II I septic abortions. In the group IIseptic abort ions the correlation is less obvious, with a highpercentage of offensive vaginal discharge and a lower percentage of positive cultures. This suggests that the breakdown of tissue might act as an addit ional source fo r thisdischarge.Suspicion of criminal intervention might still be the onlydominant clinical parameter to justify aggressive prophylactic trea tment, if t he patient would only give this in-formation more freely. Therefore all group II and i lcases of septic abortion should be regarded as c rimina

+++

+++

+++

++

+++

+

+++

++++++

Organisms

Organisms++

+

++++++

Leucocyteinfiltration+++P +P ++P +++P +++P +P ++

Degener- LeucocyteDecidua ation infi Itration

P +++ ++P +++ ++P ++ ++P ++ -'- 'TP + +++P + ++P +++ ++p ++ +P ++ ++p + ++P + ++P + +p ++ +++P ++ +P +++ ++p +++ ++P +++ +P ++ +p ++ +p + ++P + ' ,TT

Degener-Decidua ation

ppp

p

p

p

p

pP

VilliPP

pP

Villi

TABLE IV. HISTOLOGY OF GROUP 11 ABORTIONS

TABLE V. HISTOLOGY OF GROUP III ABORTIONS

No.123456789

101112131415161718192021

No.1234576

Fig. 8. Group 11 septic abortion. This histological pictureclearly demonstrates organisms, plus a posit ive neutrophilresponse. This is the reaction that should be present in al lseptic abortions.

TABLE I ll . H ISTOLOGY OF GROUP I ABORTIONS

infiltration in response to the degenerat ion of tissue, andthe presence or absence of organisms, one can see in groupI septic abortion (Table Ill) that response, with a fewexceptions is a positive neutrophil infiltration. Comparingthis with group Il abortion (Table IV), the picture changesin that the neutrophil response is more negative. Organismsare present on histological examination with fewer casesof leucocyte infiltration. Group III cases of abortion (TableV), demonstrate this negative response even further.Analysis of the positive and negative neutrophil responsesin the different types of septic abortions illustrates that in

Degener- Leucocyte Organ-No. Villi Decidua ation infiltration isms1 P P + ++2 P ++ ++3 P P ++ ++4 P ++ +5 P ++ ++6 P + +7 P P + +++.a P +9 P + ++10 P P + +

11 P P + +12 P + ++13 P P + +14 P + +15 P + +++16 P P + +17 P + ++18 P ++ +19 P P + +20 P P ++ ++21 P P ++ +22 P P ++ +

P = present; - = absent; + = slight; ++ = moderate;+++ = severe.


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11 September 1971 S.A. JOURNAL OF OBSTETRICS AND GYNAECOLOGY 41abortions and treated aggressively to prevent the development of endotoxin shock.

The mechanism of the negative neutrophil response isnot c lear at this stage and needs further investigation. Wemust expla in why without determinable infection on histo-logical examination we ge t an overwhelming positive re-sponse and with infec tion the opposite effect. This mightjustify a summary of ou r knowledge of Jeucocytes: 4

I. They are involved in various defensive and reparaLvefunc tions i n the body.2. They play an important role in the removal of 'in-vading' antigen and, prob abl y, i n th e product ion orat least transportation and distribution of the anti-body.

3. By the process of chemo taxi s, t hey a re a tt ract ed toany foreign particle, injured tissue or infective pro-cess.4. With anoxia, t he normal response is leucocytosis.5. Pregnancy produces neutrophilia as a normal reaction.6. Administration of cortisol causes neutrophilia although it diminishes the infiltration of neutrophilsinto the exudate.

1. The neutrophil response is an important means ofmeasuring the res is tance to infection. The circulatingneutrophil count may be lower than norma l, bu t,with good local re spon se in the tissues, the host re-sistance may still be normal.

With any source of infection, the f ir st cel l to make itsappearance, is the neutrophil or the macrophage. I f thiss:10uld no t happen, there is a delay in the secondary de-fence mechanisms, namely in the appearanc e o f thehaematogenous macrophages and lymphocytes, with adelay in the development of tissue oedema and conse-

Books ReceivedCarbenoxolone Sodium. Original papers and discussion of aGroup Meeting. Ed. by J. H. Baron and E M. Sullivan.Pp. xv + 171. R7.00. London and Durban: Butterworth.1971.Medical Residenfs Manual. 3rd ed. By W. J. Grace, M.D.,

F.A.C.P., R. J. Kennedy, M.D., F.A.C.P. and E B. Flood,M.D., EA.C.P. Pp. xxvii + 439. Illustrated. New York:Appleton-Century-Crofts. 1971.Ischemic Forms of Venous Thrombosis.. Phlegmasia ceruleadolens venous gangrene. By H. Haimovici, M.D. Pp. x +230. Illustrated. $23.00. Springfield, Ill.: Charles C. Thomas.197I.Progress in Clinical Medicine. 6th ed. Ed. by R. Daley, M.A.,M.D. Cantab ., F.R.C.P. and H. Miller, M.D., ER.C.P.Pp. x + 627. 5.50. Edinburgh and London: ChurchIllLivingstone. 1971.

quent tissue resistance. Under these 6rcumstances cortisolmight influence the neutrophil inf il trat ion into the exudate.

CONCLUSIONBecause of the negative neutrophil response, is it notreasonable to accept that early evacuation of t he u te ru s isimpor ta nt? In this small series, it is proved that thepresence of an acute inflammatory cell infiltration onhistological examination does not necessarily denote thepresence of infected products uf conception, or that theabortion was septic. To answer the question: 'What is aseptic abortion?', I would like t o propose the fol lowingdefinition: A septic abortion is any abortion either im-minent, incomplete or complete, where tenderness (indicating infection) can be elicited on bimanual examination.A classification of cases into groups I , II and II I accordingto the spread of infection, is suggested. With these findingsand classifications then, all group II and III cases of septicabortion should be evacuat ed vaginally without delay.I wish to thank Professor F. G. Geldenhuys, head of theDepar tment of Gynaecology and Obstetrics, for his help andencouragement; Professor J. N. Coetzee and Dr E Roux,Department of Bacteriology, for the bacteriological cultures;Professor I. Simson for his help with the preparation andinterpretation of the h'stological slides; and Dr W. H. E Kenny,Medical Super:ntendent of H. F. Verwoerd Hospi ta l, for

p ~ r ; n i s s i o n to publish.REFERENCES

1. Goodno, J. A., Cushner , 1. M. and Molumphy, P. E. (t963): Amer. J.Obstet. Gynec., 85, 16.2. Dav is , A . (1950): Brit. Med. J. , 2, 123.3. Moritz, C. R. and Thompson, N. J. (1966): Amer. J. Obstet . Gynec.,95, 46.4. Wintrobe, M. M. (1956): Clinical Hematology, p. 254. Philadelphia:Lea & Febiger.

Boeke OntvangSeptic Shock in Obstetrics and Gynecology. By H. R. K.Barber, M.D., EA.C.S., EA.C.O.G. and E. A. Graber,M.D., F.A.C.S., F.A.C.O.G. Pp. vii + 76. $4.75. Springfield,Ill.: Charles C. Thomas. 1971.Concise Medical Textbooks. Preventive Medicine, Community

Health and Social Services. 2nd ed. By J. B. MeredithDavies, M.D. (Lond.), D.P.H. Pp. x + 331. 1.75. London:Bailliere Tindall. 1971.Advances in Planned Parenthood. Vol. VI. Proceedings of the8th annual meeting of the Amer ican Association ofPlanned Parenthood Physicians. Ed. by A. J. Sobrero, M.D.and R. M. Harvey. Pp. viii + 180. Illustrated. Dfl. 45,00.Amsterdam: Excerpta Medica. 1971.Handbook of Leprosy. By W. H. Jopling, ER.C.P. (Edin.),M.R.C.P. (Lond.), D.T.M. & H. (Eng.). Pp. 91. Illustrated.1.15. London: William Heinemann Medical Books. 1971.

2.5 the Parameters of Septic Abortion. m. Botes

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