¹Department of Obstetrics and Gynecology, Konstandopoulio General Hospital, Athens, Greece
²Intensive Care Unit, Konstandopoulio General Hospital, Athens, Greece
*Corresponding Author: Chrisostomos Sofoudis, Department of Obstetrics and Gynecology, Ippokratous str. 209, 11472, Athens,Greece, E-mail: firstname.lastname@example.org
Cite this article: Sofoudis C. Septic Abortion Accompanied with Dessiminated Intravascular Coagulation and Acute Cardiomyopathy Presentation
of a Rare Case and Mini Review. Am J Nur & Pract. 2018;1(1): 001-00.
Submitted: 27 February 2018; Approved: 29 March 2018; Published: 30 March 2018
Introduction: Septic abortion represents a common entity of maternal death, demonstrating a variety of clinical conditions. In the obstetric field, chorioamnionitis, a membrane rupture due to vaginal or urinary tract infection can lead to septic abortion, and in extreme conditions to dessiminated intravascular coagulation, a life threatened condition for the mother and the fetus. Chrioamnionitis, is strongly associated with increased preterm labor rate and child development disorders.
Objective: Presentation of a rare case of septic abortion well-diagnosed and proper treated.
Methodology: Assiduous depiction of case presentation and current literature.
Result: Proper treatment and counseling regarding the clinical management of such cases
Conclusion:Presentation of a 35-year-old female patient, in the 17th week of gestation after second IVF attempt. After research laparotomy due to diffuse abdominal pain and automatically membrane rupture, the patient underwent therapeutic uterus evacuation. Through all these procedures
the mechanismus of dessiminated intravascular coagulation was activated, leading to vaginal bleeding and haemorrhagic shock. The patient
admitted to the intensive care unit, properly treated with antimicrobial agents and colloid fluids, necessary clinical tools concerning the treatment of
Pregnancy represents the time period, in which one or more
offspring develop inside a uterus . Symptoms of early pregnancy may include missed periods, tender breasts, nausea and vomiting,hunger, and frequent urination.
According to current bibliography, there is a decrease of annual complications during pregnancy, estimated at 293,000 deaths
in 2013, in comparison with 377,000 deaths in 1990. The most
common causes consist of vaginal bleeding, blood hypertension
during gestation, abortion accompanied with vaginal or urine tract
infections, leading to maternal sepsis and obstructed labor.
Septic abortion reflects a life threating maternal condition
with a constant increased rate of 0.4 to 0.6 per 100.000 spotaneous
The pathogenetic mechanismus of septic abortion occurs
through infected vaginal or urine channel and spreads in the whole
peritoneal cavity causing septicemia .
Septicemia, a spread infection through blood vessels, reflects a
life threating condition with ultimate establishment the activation
of septic shock and disseminated intravascular coagulation.
Many bacterial agents are responsible for the completion
of this pathogenetic procedure. Key representatives are mainly
gram-negative organisms, such as Escherichia coli, Klebsiella pneumonia,
Proteus species and most of all chlamydial infections .
The objective of the following case presentation reflects the
proper diagnosis and treatment of a maternal life threating condition
such as septic abortion. Factors such rapidly disease spread,
hemodynamic instability and ventilation of the patient, always
affect the final clinical mapping.
We present a rare case of a 35-year-old female patient admitted
to our Department in the 17th week of gestation after second
IVF attempt. The patient, with no family history, complained of
diffuse abdominal pain. The physical examination revealed intense
abdominal sensitivity and muscular contraction. During the last
three days, she reported abdominal swelling and interruption of
gases and feces. (positive Murphy, rebound and Jiordano sign)
The laboratory examination consisted of increased range
of white blood cells and inflammatory markers. The gynecological
examination did not reveal signs of pathology. (T:37,7 C, WBC
17.800, CRP 38, 5 U/L, Blood pressure 110/60 mmHg, SaO2 98%)
According to the U/S report, there was plenty amount of
amniotic fluid without any sign of membrane rupture and positive
fetal heart pulse. Due to previous clinical and imaging examination,
the patient admitted to the surgical Department. Assiduous
clinical examination revealed intention of abdominal pain at the examination revealed intention of abdominal pain at the
left iliac fossa and left renal region. The patient was subjected to
potent antimicrobial treatment.
After a short period of time, there was a decrease of all hemodynamic
parameters of the patient. (WBC 19.800, Hct 28.9%, Hb
9.5 g/dl, CRP 65, 84mg/L). Next to the automatically membrane
rupture, there was increased abdominal pain and muscular contractions,
signs of preterm labor (positive fetal heart pulse).
Due to increased and located abdominal pain the patient
underwent exploratory laparotomy not revealing any signs of surgical
pathology. Meanwhile, the cervical dilatation was increased,
measuring 3-4 cm.
With the administration of uterus contractile solutions, such
as Oxytocin solutions, the patient underwent therapeutic evacuation
of the uterus. (negative fetal heart pulse.) This procedure
consisted of fetal and placental evacuation accompanied with
diagnostic curettage. Amniotic fluid, part of the placenta, membrane
and vaginal fluid were sent for diagnostic cultivation, part
of the placenta membrane and part of the umbilicus were sent for
The cultivation results revealed Klebsiella infection. The
histopathologic examination revealed placenta of 17th week of
gestation, high level maternal necrotic chorioamnionitis, increased
fetal inflammatory response, peripheral hematoma and peripheral
Final result was the establishment of transcervical Klebsiella
infection. At the end of these procedures, the patient admitted to
the Surgical Department.
Due to an intense vaginal bleeding, there was an affection of
the hemodynamic status of the patient. Final step, admission to the
surgery room with signs of atonic uterus and haemorrhagic shock.
She underwent diagnostic curettage with presence of diffuse vaginal
bleeding. (systematic arterial blood pressure 50 mm Hg and
Hct 18%). In order to avoid vaginal bleeding, vaginal and cervical
tamponade was mandatory.
Next step, the activation of disseminated intravascular coagulation.
The patient was supported with 5 units of packed red blood
cells, 5 units of platelets and 3units of frozen plasma, coagulation
factors, crystalloid and colloid solutions. She revealed renal disturbances
with signs of oliguria as complication of the haemorrhagic
shock. She was supported with enormous doses of furosemide.
Due to episodes of lung constriction entered the fact of pulmonary
embolism. For the evaluation of septic areas, the patient after the
surgery underwent CT thorax-upper and lower abdomen.
The CT examination revealed pulmonary areas of atelectasis
and areas of pleural fluid collection. In the abdominal cavity there
was fluid collections around the liver and behind the peritoneal
cavity. All the abdominal organs showed no signs of malignancy.
The patient was admitted to the Intensive Care Unit (Figures I,II).
Despite the difficulties of ventilation, the patient was supported
with crystalloid and colloid fluids and low doses of vasoconstricted
solutions. Due to endometrial, there were increased doses
of anti-microbial agents, such as Meropenem, Flagyl and Voncon.
The inflammatory markers were increased, with disturbances of
coagulation such as thrombocytopenia and decreased ranges of
fibrinogen. The U/S evaluation revealed enormous decrease of the
myocardial function with ejection rate 30%. (sign of cardiac insufficiency).
The following day, there were episodes of fever, increase
of the inflammatory markers with stabilization of the hemodynamic
support, without signs of increased vaginal bleeding or abdominal
pathology. Managing the fact of the intrabdominal sepsis, the
patient was supported with doses of Meropenem, Briklin, Tygacil,
Azithromycin and Fluconazole.
The new abdominal CT did not show any signs of pathology.
After a period, there was a stabilization of the hemodynamic status,
increased of the renal function and decrease of all inflammatory
markers (Table II).
The patient had normal neurological status, autonomic ventilation
and renal function. She started per us feeding. She was discharged
to the gynecologic Department.
Due to Rhesus negative, the patient underwent anti-D- immune
globulin injection and pharmaceutical milk interruption. After a
few days, she was discharged from the hospital in good clinical
Septic shock represents a life threating clinical syndrome as
result of severe infection and sepsis. The insertion of viruses and
bacteria into the blood circulation lead to the so-called viremia or
As result of all these procedures, the human organism creates
the sepsis syndrome. According to current bibliography, the global incidence estimates
between 25 and 50% .
Acute chorioamnionitis is usually caused by ascending infection
that can precipitate premature rupture of membranes and
delivery. The bacteria most commonly isolated from cases of chorioamnionitis
are Escherichia coli, coagulase positive Staphylococcus,
Haemophilus vaginalis, Streptococci, Listeria monocytogenes
and other Gram-negative bacilli .
Besides the clinical figures and complications of acute chorioamnionitis
there are always clinical and amniotic fluid laboratory
signs, which certify the acute lesion (Table I).
As we mentioned above, many bacteria have been reported as
culprit organisms, regarding the aetiology of placental infection.
Passing through the current bibliography there are few cases in
the literature of acute placental infection caused by Klebsiella
pneumoniae. The emphasis of this reason, is to underline the proper
diagnosis and treatment of this clinical procedure. Klebsiella
species are an important element of the of the normal flora of gastrointestinal
tract. The clinical range varies, including pneumonia,
urinary tract infections, bacteraemia and a chronic granulomatous
disease of the upper airways .
When the clinical status of the lesion is worsening, there is a
possibility of the activation of the Dessiminated Intravascular Coagulation
(DIC) mechanismus. This chronical point is very crucial
for the clinical status of the patient. It represents a spontaneous intravascular
activation of coagulation. The main pathophysiological
mechanisms of DIC are inflammatory cytokine-initiated activation
of tissue factor-dependent coagulation, insufficient control of anticoagulant
pathways and plasminogen activator inhibitor 1-mediated
suppression of fibrinolysis .
Together, these changes give rise
to endothelial dysfunction and microvascular thrombosis, which
can cause organ dysfunction and seriously affect patient prognosis.
In our case, there was an immediate activation of the DIC
mechanismus. As result of this procedure, all coagulation factors
were consumed with ultimate goal the enormous vaginal bleeding
of the patient.
The answer to this clinical status is strongly associated with
immediate and proper diagnosis and treatment.
Septic abortion represents a rare entity with severe intra- and
postoperative complications. Our case consisted of a life threating
procedure, well diagnosed and proper treated. Ultimate goal remains
the disciplinary cooperation between gynecologists, general
surgeons and anesthesiologists with scope the patient quality of
Table I: Clinical and amniotic fluid laboratory diagnosis of
chorioamnionitis Tita ΑΤΝ et al, Clin Perinatol. 2010
twice or>101 once
> 100/ min
Bacteria or white blood
99% specific 
74% specific 
75% specific 
80% specific 
White blood cell
78% specific 
Table II: Chronical Diagramm ( Intensive Care Unit)
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