Correspondence

Management of Septic Abortion

N Engl J Med 1994; 331:1716-1717December 22, 1994

Article

To the Editor:

In their otherwise excellent article (Aug. 4 issue),1 Stubblefield and Grimes mention the means of emptying the uterus in the case of a retained fetus from a midtrimester abortion. Unquestionably, as they state, an “experienced practitioner can usually evacuate the uterus successfully with curettage guided by ultrasonography,” but it should be emphasized that the major part of the retained secundines has to be removed with an ovum forceps. The suction curette will help mainly at the end of the procedure, to remove smaller fragments of tissue.

Prostaglandins are highly effective in terminating second-trimester abortion, but they may be considerably less effective in severe cases of septic abortion, when metritis has developed and the myometrium does not respond well to oxytocic stimulation. Precious time may be lost, during which the condition of the patient may worsen.

I take issue with the statement that “high doses of oxytocin can be used.” Oxytocin is a much less effective uterine stimulant than prostaglandins at this stage of gestation. Furthermore, at the doses mentioned (50 to 300 units), it has a marked antidiuretic effect and causes fluid retention, which may further complicate the clinical picture. If oxytocin is not administered in normal saline (as recommended by the authors), potentially lethal water intoxication (severe hyponatremia) may develop.

Again, as the authors correctly stress, it is essential that retained products of conception be evacuated without delay. In septic abortion, surgical evacuation is much superior to pharmacologic means.

Jean-Jacques Amy, M.D.
Vrije Universiteit Brussel, 1090 Brussels, Belgium

1 References

1. 1

   Stubblefield PG, Grimes DA. Septic abortion. N Engl J Med 1994;331:310-314
   Full Text | Web of Science | Medline

To the Editor:

The review by Stubblefield and Grimes begins with a case report published in the Journal in 1973 about a 15-year-old girl with septic abortion.1 Correct treatment was delayed because this diagnosis was not considered. The authors refer to the case as a tragedy. I agree.

In the same year, 1973, Lanari et al. reported the experience of the Instituto de Investigaciones Medicas, Universidad de Buenos Aires, in Medicina (a journal published in Buenos Aires, Argentina).2 The authors described 150 patients with septic abortion and renal insufficiency and emphasized that hysterectomy has no place in the treatment of such patients unless there is uterine perforation or uterine gangrene.2

The report by Lanari et al. has 31 pages (1 with color photographs) and 106 references and is written in Spanish with a long English summary. It is amazing that 21 years later a review of septic abortion does not mention this report and that only 1 of the 49 articles cited is in a language other than English. It seems unfair that some U.S. experts do not care about papers not written in English.

Javier D. Finkielman, M.D.
Hospital de Clinicas Jose de San Martin, 1120 Buenos Aires, Argentina

2 References

1. 1

   Jewett JF. Septic induced abortion. N Engl J Med 1973;289:748-749
   Medline

2. 2

   Lanari A, Firmat J, Paz RA, Rodo JE. El aborto septico con insuficiencia renal aguda: estudio sobre 150 casos. Medicina (B Aires) 1973;33:331-360
   Web of Science | Medline

Author/Editor Response

The authors reply:

To the Editor: Dr. Amy is correct in stating that surgical evacuation of the uterus in midtrimester relies primarily on the use of ovum forceps, with the suction curette serving mainly as an adjunct. However, until about 16 weeks of gestation (dating from the last menstrual period), a 14-mm suction cannula alone is usually adequate to empty the uterus. As Dr. Amy suggests, prostaglandins may be less effective in stimulating uterine contractions when the myometrium is badly infected. We are unaware of any studies of uterine contractility under these circumstances.

Water intoxication is an entirely preventable complication of oxytocin administration. Deaths from water intoxication in the United States no longer occurred once physicians became more sophisticated in administering the drug. As we note, periodic allowance for diuresis (e.g., one hour out of four) makes the administration of high-dose oxytocin safe.1

Although we agree with Dr. Amy that surgical evacuation is usually preferable to pharmacologic methods, medical induction of labor has the advantage of requiring less surgical skill. This may be important in developing countries or wherever procedures for midtrimester dilatation and evacuation are not performed routinely. We agree with his recommendation of prompt uterine evacuation with septic abortion. Delays can be deadly.

Dr. Finkielman notes that most of the articles we cite are in English. Our reference list includes reports from many countries and one report in Spanish, but we could include only a limited number of references in our review. As Dr. Finkielman suggests, physicians around the world, many writing in languages other than English, have made important contributions to the management of septic abortion.

Phillip G. Stubblefield, M.D.
Maine Medical Center, Portland, ME 04102-3175

David A. Grimes, M.D.
San Francisco General Hospital, San Francisco, CA 94110-3594

1 References

1. 1

   Winkler CL, Gray SE, Hauth JC, Owen J, Tucker JM. Mid-second-trimester labor induction: concentrated oxytocin compared with prostaglandin E2 vaginal suppositories. Obstet Gynecol 1991;77:297-300
   CrossRef | Web of Science | Medline