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
SUMMARY
A retrospective analysis of 50 cases of septic incomplete
abortion is made. The clinical picture, discharge,
bacteriologic cultures of the cervix and uterine cavity
and the histopathological picture of the uterine curette-
ments are correlated. Certain conclusions and suggestions
based on the results of this project are made.
S. Afr. J. Obstet. Gynaec., 9, 37 (1971).
When considering the problem of septic abortion, the
following questions come to mind: What is a septic abor-
tion? How can a case of septic abortion be identified? If
identified, should it be treated by immediate evacuation,
or by evacuation only after the patient is afebrile?
Answers to these questions from the available literature
are difficult to obtain and are often contradictory.
The diagnosis of septic abortion-in a pregnant patient
with vaginal bleeding and pyrexia, and after excluding an
extra-uterine source of infection-may be made in the
presence of one or more of the following signs and symp-
toms:'
1. A history of criminal intervention. (Such information
can be obtained from about 30% of patients, but only
after 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 defini-
tions are based on the assumption that a raised temperature
is present. Davis' in his clinical survey of 2665 cases of
abortion, found an elevation of temperature in 84%. To
prevent sequelae of septic abortion, early therapy is the
sine qua non of a favourable outcome. Does this therefore
imply that 84% of the abortions admitted must be treated
aggressively? If not, what parameters should be employed
to estabUsh the diagnosis?
This study was based on the definition of Moritz and
Thompson,' viz.: A septic abortion is any abortion, either
threatened, imminent, incomplete or complete in which the
endometrial cavity and / or its contents are infected by any
means. To evaluate the spread of infection, we grouped
the septic abortions into 3 types: 1
Group I: Cases with infection limited to the uterus
alone.
Group IT: Cases with extra-uterine spread of infec-
tion to parametrium and/or adnexa.
Group Ill: Cases with pelvic or generalized peritonitis.
These groupings were determined clinically. Group I
septic abortion was diagnosed even in the absence of
pyrexia.
presented at the Interim Congress of the South African Society of
Obstetricians and Gynaecologists (M.A.S.A.). Bloemfontein. March 1970.
The purpose of the project was (i) to correlate bacterial
cultures with the clinical classification and with special
reference to the offensive vaginal discharge; (ii) to deter-
mine whether there is a dominant clinical parameter; and
(iii) to evaluate, after consideration of (i) and (ii), whether
endotoxic shock can be prevented by prophylactic treat-
ment.
MATERIALS AND METHODS
For the purpose of this study, 50 cases of septic incomplete
abortion were grouped according to the abovementioned
classification. The case histories, clinical data and labora-
tory findings were compiled and filed on a special question-
naire form for further correlation. In order to solve the
question of possible criminal iJ11tervention, an effort was
made to determine whether the pregnancy was desired.
Marital status and history of previous pregnancies and
abortions were noted. If, after a direct question to the
patient as to whether attempts had been made to terminate
the pregnancy, any doubt existed, the case was included in
the criminal intervention group.
In order to obtain all clinical information, every patient
on admission underwent a thorough general and vaginal
examination. When inserting 1he vaginal speculum no
lubrication was used, and a swab was taken from the upper
third of the vagina and from the cervical canal. The cervix
was then cleaned with chlorhexadine, dried with sterile
gauze, and a sterilized glass cannula was inserted through
the cervical canal into the uterine cavity. A swab of the
uterine contents was then taken through this cannula
(Fig. 1). Both cervical and uterine swabs were cultured
Fig. 1. Glass cannula with throat swab.
within 3 hours, aerobically and anaerobically, and drug
sensitivity tests were performed on all cultures. The time
interval between admission and curettage was noted,
and the products of conception were fixed in 4% formalde-
hyde. Histopathological examination was performed with
special care to confirm the diagnosis of pregnancy, i.e. the
presence of villi and decidua. The degree of degeneration
of the products of conception were estimated as well as
leucocyte infiltration and the number of bacterial colonies_
38 S.A. TYDSKRIF VIR OBSTETRIE EN GINEKOLOOIE 11 September 1971
Fig. 2 shows the correlation between the offensive vaginal
discharge and the bacteriological cultures. In the cases
where infection was limited to the uterus (group I), only
14% had offensive vaginal discharge, although 23% yielded
positive cervical cultures and 9% positive uterine cultures.
of no growth, although they were imbedded within the
3-hour period. This matter is being investigated further.
The uterine cavity cultures (T".hle IT) were also domi-
nated by the pathogenic organism E. coli, either alone or
in combination. The high percentage of swabs resulting in
no growth, is what one would expect from the uterine
cavity.
TABLE 11. UTERINE CAVITY SWAB CULTURES
50
4
2
1
1
1
3
1
37
III
Type 3
o
Type 2
86
71

Type 1
57
43
33
23
I I11
9
I
PARAMETERS of I FECTION
offensive
vaginal
discharge
cervical
culture
E. coli
E. coli + Aerobacter aerogenes
Proteus + Beta haemolytic streptococcus
Proteus vulgaris + E. coli
Aerobacter aerogenes
Proteus mirabilis + E. coli
Beta haemolytic
No growth
uterine
culture
The results of the investigations presented here should be
regarded as a preliminary report, as a larger series is con-
templated. According to the previously mentioned clinical
classification, the 50 cases of septic incomplete abortions
were grouped as follows: 22 cases (44%) where tenderness
was confined to the uterus (group I); we had 21 cases
(42%) where spread of infection to parametrium and/or
.adnexa was present (group H); and 7 cases (14%) with
pelvic or generalized peritonitis (group IH).
The period of time between commencement of abortion
.and admission was noted, because of the commonly held
belief that the longer this interval, the greater the incidence
of septic abortion. In this series, however, there was no
correlation, as the interval was 22 days in group I cases,
.30 days in group Hand 21 days in group HI.
The mean temperature on admission, was 989F in
.group I, 101F in group H, and 1024OF in group IH. The
increase in temperature was therefore directly proportional
to the clinical spread of infection. In other words, group I
.and group H septic abortions fit into the definitions men-
tioned by other authors. These authors stress pyrexia as
being the most dominant clinical parameter, and they also
stress the point that the patient should be afebrile before
doing a vaginal evacuation. At H. F. Verwoerd Hospital,
we do not accept elevated temperature as the only domi-
nant clinical parameter, nor does the presence of elevated
temperature usually prevent us from taking the patient to
theatre for vaginal evacuation.
A further finding was that of the cases with a history of
criminal intervention 9(, were in group I, 57% in group
II, and 86% in group HI. This distribution confirms that in
cases with extra-uterine spread of infection, there is a
strong 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 dominant
organism is E. coli, either alone or in combination with
other organisms. A high percentage of swabs gave results
TABLE I. CERVICAL SWAB CULTURES
E. coli (alone)
E. coli + Aerobacter aerogenes
Coag. pos. staph.
Aerobacter aerogenes
Proteus mirabilis + Aerobacter aerogenes
E. coli + Proteus vulgaris
Proteus + Beta haemolytic streptococcus
Proteus + E. coli + Beta haemolytic streptococcus
lactobacillus + Doderlein's bacillus
No growth
9
2
2
2
1
1
1
2
1
29
50
71
10 20 30 40 50 60 70 80 90 100
Percenrage
Fig. 2. Correlation of discharge with bacteriological cul-
tures.
In the group 11 cases (extra-uterine spread of infection to
parametrium or adnexa) the positive cervical and uterine
cultures were less than the incidence of offensive vaginal
discharge. By comparison, the cases with peritonitis (group
HI) showed a very strong correlation: 71 % offensive dis-
charge with 86% positive cervical cultures and 71 % positive
uterine cultures.
The histopathological results were unexpected. The
histological basis for the diagnosis of infected products of
conception is the presence of an infiltrate of acute inflam-
matory cells. Fig. 3 shows the histological picture of a
11 September 1971 S.A. JOURNAL OF OBSTETRICS AND GYNAECOLOGY
39
Fig. 6. Group n septic abortion. Bacterial colony present
and no neutropbils-negative neutrophil response.
Fig. 7. Group III septic abortion with a negative neutrophil
response.
Fig. 5. Group n septic abortion. Organisms present, with
a negative neutrophil response.
Tabulating the histological findings in the different clini-
cal types of septic abortion according to the leucocyte
t"

Fig. 4. Group ID septic abortion: histology.

case of spontaneous abortion classified as group I, i.e.
uterine tenderness and a normal temperature. The striking
features are the extent of neutrophil leucocyte infiltration,
the minimal degeneration of products of conception, and
the absence of organisms. This finding has been termed
the positive neutrophil response.
Fig. 3. Group I septic abortion: histological picture.
Fig. 4 shows the histological picture of a patient from
group III who developed a temperature of I022F. There
is minimal neutrophil infiltration, bacterial colonies are
present and there is no degeneration of products of con-
ception. This finding has been termed a negative neutro-
phil response. Figs 5 - 7 are lhe histological pictures of
group II and group ID septic abortions, which further
illustrate this negahve response.
Fig. 8 is the histological picture of a group II septic
abortion showing, as expected, organisms plus a positive
neutrophil response--in other words, a neutrophil leucocyte
infiltration to combat the amount of organisms.
40 S.A. TYDSKRIF VIR OBSTETRIE EN GINEKOLOGIE
11 September 1971
DISCUSSION
group I there is a 75% posllive and a 25% negative re-
sponse. Group Il shows a 40% positive and a 60% negative
response, while group III has a 30% positive and a 70%
negative response. It appears that the more overwhelming
the infection, the less is the response of the body against
this infection.
The presence of a salmon-pink offensive uterine discharge
as the result of an intra-uterine infection can be clearly
seen in the group III septic abortions. In the group II
septic abortions the correlation is less obvious, with a high
percentage of offensive vaginal discharge and a lower per-
centage of positive cultures. This suggests that the break-
down of tissue might act as an additional source for this
discharge.
Suspicion of criminal intervention might still be the only
dominant clinical parameter to justify aggressive prophy-
lactic treatment, if the patient would only give this in-
formation more freely. Therefore all group II and ill
cases of septic abortion should be regarded as criminal
+++
+++
+++
++
+++
+
+++
+++
+++
Organ-
isms
Organ-
isms
++
+
+
+
++
++
Leucocyte
infiltration
+ p ++
P +
P ++
P +++
P +++
P +
P ++
Degener- Leucocyte
Decidua ation infi Itration
P +++
++
P +++ ++
P ++ ++
P ++
-'- ' , T
P + +++
P + ++
P +++ ++
p
++ +
P ++ ++
p
+ ++
P + ++
P + +
p
++ +++
P ++ +
P +++ ++
p
+++ ++
P +++ +
P ++
+
p
++
+
p
+ ++
P +
' ,
TT
Degener-
Decidua ation
p
p
p
p
p
p
p
p
P
Villi
P
P
p
P
Villi
TABLE IV. HISTOLOGY OF GROUP 11 ABORTIONS
TABLE V. HISTOLOGY OF GROUP III ABORTIONS
No.
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
No.
1
2
3
4
5
7
6
Fig. 8. Group 11 septic abortion. This histological picture
clearly demonstrates organisms, plus a positive neutrophil
response. This is the reaction that should be present in all
septic abortions.
TABLE Ill. HISTOLOGY OF GROUP I ABORTIONS
infiltration in response to the degeneration of tissue, and
the presence or absence of organisms, one can see in group
I septic abortion (Table Ill) that response, with a few
exceptions is a positive neutrophil infiltration. Comparing
this with group Il abortion (Table IV), the picture changes
in that the neutrophil response is more negative. Organisms
are present on histological examination with fewer cases
of leucocyte infiltration. Group III cases of abortion (Table
V), demonstrate this negative response even further.
Analysis of the positive and negative neutrophil responses
in the different types of septic abortions illustrates that in
Degener- Leucocyte Organ-
No. Villi Decidua ation infiltration isms
1 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.
11 September 1971
S.A. JOURNAL OF OBSTETRICS AND GYNAECOLOGY
41
abortions and treated aggressively to prevent the develop-
ment of endotoxin shock.
The mechanism of the negative neutrophil response is
not clear at this stage and needs further investigation. We
must explain why without determinable infection on histo-
logical examination we get an overwhelming positive re-
sponse and with infection the opposite effect. This might
justify a summary of our knowledge of Jeucocytes: 4
I. They are involved in various defensive and reparaLve
functions in the body.
2. They play an important role in the removal of 'in-
vading' antigen and, probably, in the production or
at least transportation and distribution of the anti-
body.
3. By the process of chemotaxis, they are attracted to
any foreign particle, injured tissue or infective pro-
cess.
4. With anoxia, the normal response is leucocytosis.
5. Pregnancy produces neutrophilia as a normal re-
action.
6. Administration of cortisol causes neutrophilia al-
though it diminishes the infiltration of neutrophils
into the exudate.
1. The neutrophil response is an important means of
measuring the resistance to infection. The circulating
neutrophil count may be lower than normal, but,
with good local response in the tissues, the host re-
sistance may still be normal.
With any source of infection, the first cell to make its
appearance, is the neutrophil or the macrophage. If this
s:10uld not happen, there is a delay in the secondary de-
fence mechanisms, namely in the appearance of the
haematogenous macrophages and lymphocytes, with a
delay in the development of tissue oedema and conse-
Books Received
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Group 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.,
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quent tissue resistance. Under these 6rcumstances cortisol
might influence the neutrophil infiltration into the exudate.
CONCLUSION
Because of the negative neutrophil response, is it not
reasonable to accept that early evacuation of the uterus is
important? In this small series, it is proved that the
presence of an acute inflammatory cell infiltration on
histological examination does not necessarily denote the
presence of infected products uf conception, or that the
abortion was septic. To answer the question: 'What is a
septic abortion?', I would like to propose the following
definition: A septic abortion is any abortion either im-
minent, incomplete or complete, where tenderness (indi-
cating infection) can be elicited on bimanual examination.
A classification of cases into groups I, II and III according
to the spread of infection, is suggested. With these findings
and classifications then, all group II and III cases of septic
abortion should be evacuated vaginally without delay.
I wish to thank Professor F. G. Geldenhuys, head of the
Department of Gynaecology and Obstetrics, for his help and
encouragement; Professor J. N. Coetzee and Dr E Roux,
Department of Bacteriology, for the bacteriological cultures;
Professor I. Simson for his help with the preparation and
interpretation of the h'stological slides; and Dr W. H. E Kenny,
Medical Super:ntendent of H. F. Verwoerd Hospital, for
p ~ r ; n i s s i o n to publish.
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