Rare but severe infections with otherwise low-virulence organisms can complicate medical or spontaneous abortions. Deaths have been reported from toxic shock syndrome due to Clostridium peringens (Centers for Disease Control and Prevention, 2005). Similar infections are caused by Clostridium sordellii and have clinical manifestations that begin within a few days after an abortion. Women may be afebrile when first seen with severe endothelial injury, capillary leakage, hemoconcentration, hypotension, and a profound leukocytosis. Maternal deaths from these clostridial species approximate 0.58 per 100,000 medical abortions (Meites, 2010).
Management of clinical infection includes prompt administration of broad-spectrum antibiotics as discussed in Chapter 37 (p. 668). If there are retained products, then suction curettage is also performed. Most women respond to this treatment within 1 to 2 days and are discharged when afebrile. Follow-up oral antibiotic treatment is likely unnecessary (Savaris, 2011). In a very few women, severe sepsis syndrome develops, and intensive supportive care is essential. Although rare, clinical decline in the patient and widespread peritonitis despite curettage should raise concerns. Imaging that shows free air or air within the uterine wall typically prompts laparotomy (Eschenbach, 2015). If the uterus is necrotic, hysterectomy is indicated.
With spontaneous miscarriage, 2 percent of h D-negative women will become alloimmunized if not provided passive isoimmunization. With an induced abortion, this rate may reach 5 percent. The American College of Obstetricians and Gynecologists (2017g) recommends anti-Rho (D) immunoglobulin given as 300 �g intramuscularly (IY!) for all gestational ages. Doses may also be graduated, with 50 �g given Hvl for pregnancies :;12 weeks and 300 �g for ::13 weeks. This is administered immediately following surgical evacuation. For planned medical or expectant management, the injection is given within 72 hours of pregnancy failure diagnosis.
With threatened abortion, immunoglobulin prophylaxis is controversial because of sparse evidence-based data (Hannafin, 2006). hat said, it is reasonable to administer anti-D immunoglobulin for a threatened abortion and a live fetus, and this is our practice.
Afecting approximately 1 percent of fertile couples, recurrent pregnancy loss (RPL) is classically deined as three or more consecutive pregnancy losses <20 weeks' gestation or with a fetal weight < 500 g. Mindful of this threshold, data from two large studies showed the risk for a subsequent miscarriage to be similar whether following two or three prior pregnancy losses (Bhattacharya, 2010; Brigham, 1999). And, the American Society for Reproductive Medicine (2013) now deines RPL as two or more failed pregnancies conirmed by sonographic or histopathological examination. Primary PL refers to multiple losses in a woman who has never delivered a liveborn, and secondary PL refers to multiple pregnancy losses in a patient with a prior live birth. Remarkably, the chances for a successful pregnancy arei> 50 percent even after five losses (Table 18-4).
TABLE 18-4. Predicted Success Rate of Subsequent Pregnancy According to Age and Number of Previous Miscarriages
No. of Previous 2 3 4 5 Miscarriages at Predicted Success of Subsequent
Evaluation for RPL addresses the major etiologies, described next (American Society for Reproductive Medicine, 2012). Treatment considerations reach beyond the scope of this book, and interested readers are referred to Chapter 6 in Wiliams Gynecoloy, 3rd edition (Halvorson, 2016).