Images in Emergency Medicine
Article Outline
[Ann Emerg Med. 2007;50:e1.]
A 23-year-old woman, gravida 8, para 3, with a last menstrual period 3 months before and an intrauterine device (IUD) placed 2 months before, presented to the emergency department with crampy lower abdominal pain and vaginal discharge for 1 day. She denied fever, chills, back pain, or urinary symptoms. Her vital signs were notable for a low-grade fever (100.0 °F-37.8°C). Her physical examination was notable for mild bilateral lower abdominal tenderness, a purulent discharge from the cervical os with no visible IUD strings, and uterine tenderness. A urine pregnancy test was positive. Her WBC count was 24.4×109/L, and β-human chorionic gonadotropin was 188,087 mIU/mL.
Diagnosis
Intrauterine twin gestation with single live intrauterine pregnancy, single septic abortion, and an IUD
Transvaginal pelvic ultrasonography revealed a twin intrauterine gestation, with twin 1 adjacent to the internal cervical os, twin 2 positioned superiorly, and an IUD between them (Figure). Twin 1 had no surrounding amniotic fluid or cardiac motion. Twin 2 was anatomically normal, with a normal pulse rate. Intravenous antibiotics were administered. The patient spontaneously aborted both fetuses the next morning.
Figure.
Transvaginal pelvic ultrasound showing coronal image throug the uterus. Used with permission of Christopher Fee, MD, Division of Emergency Medicine, Department of Medicine, University of California, San Francisco Medical Center, San Francisco, CA.
Septic abortions occur when retained products from spontaneous or therapeutic abortions become infected, usually with mixed vaginal flora or sexually transmitted bacteria such as Escherichia coli and other aerobic, enteric, and Gram-negative rods; group B β-hemolytic streptococci; staphylococcal organisms; and Bacteroides species, Neisseria gonorrhoeae, Chlamydia trachomatis, Clostridium perfringens, Mycoplasma hominis, and Haemophilus influenzae. IUDs and medical termination have been associated with septic abortions.1, 2, 3, 4 Pelvic inflammatory disease is the most common complication. Septic abortion was once the leading cause of maternal death worldwide, mostly because of illegal abortions. Mortality increases with gestational age. Women of childbearing age presenting with fever, abdominal pain, vaginal discharge, or bleeding should be evaluated for possible septic abortion with thorough examinations, laboratory testing, and imaging. Ultrasonography may identify intrauterine-retained products of conception, adnexal masses, or free pelvic fluid. Consult obstetrics and gynecology personnel if the diagnosis is considered.
Early, broad-spectrum antibiotics and prompt uterine evacuation are recommended. Laparotomy may be required in cases of treatment failure, with hysterectomy reserved for severe uterine perforation, bowel injury, clostridial myometritis, and pelvic abscess.
References
- . Mid-trimester septic abortion and Escherichia coli septicaemia in a copper IUCD user. BMJ. 1978;1:481–482
- . Septic abortion in women using intrauterine devices. BMJ. 1975;4:263–264
- . Septic abortion associated with a Lippes loop. BMJ. 1975;3:747–748
- Fatal toxic shock syndrome associated with Clostridium sordellii after medical abortion. N Engl J Med. 2005;353:2352–2360
PII: S0196-0644(07)00380-0
doi:10.1016/j.annemergmed.2007.03.019
© 2007 American College of Emergency Physicians. Published by Elsevier Inc. All rights reserved.
