Management of STIs/RTIs
Chapter 9. STI/RTI complications related to pregnancy, miscarriage, induced abortion, and the postpartum period

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Infection in early pregnancy

Upper genital tract infection is different in pregnant than in non-pregnant women. Women with pre-existing pelvic inflammatory disease have difficulty becoming pregnant�acute infection in the uterus interferes with fertilization and implantation of the ovum, while established PID may cause scarring, infertility and ectopic pregnancy. Almost all infections that do occur develop during the pregnancy itself, usually because of some event that disrupts the body�s normal defences.

Most infectious complications of early pregnancy are related to spontaneous or induced abortion. Spontaneous abortion (or miscarriage) is common in the first trimester and usually resolves without complication. Induced abortion is also common and risk of infection is high when it is performed in unsafe conditions. Spontaneous or induced abortion is incomplete when tissue remains inside the uterus, and infection may develop if any remaining products of conception are not removed.

Such details are not always apparent when a woman seeks medical care for abortion complications. In fact, women with problems following induced abortion may not mention having had a procedure, especially in places where abortion is illegal. They may simply complain of spontaneous bleeding or other problems instead. Health care providers should thus have a high index of suspicion and manage possible infection following abortion based on objective signs, regardless of history.

 

Management of postabortion complications

The treatment of complicated abortion includes stabilization of the patient, removal of remaining products of conception from the uterus, and administration of intravenous or intramuscular antibiotics (Flowchart 6, Treatment table 11). Abortion complications can be life-threatening and timely assessment and management are critical. A rapid assessment �short history, vital signs, general examination and abdominal and genital examination�should be performed and emergency treatment started. Women with signs of shock should be stabilized with intravenous fluids. All women with signs of shock or infection in early pregnancy should be given the first dose of antibiotics intravenously or intramuscularly, and referred immediately to a facility that can provide appropriate management, including safe evacuation of the uterine contents.

 

FLOWCHART 6. Possible complications of abortion

 

Incomplete abortion and risk of infection

Bleeding in early pregnancy may indicate that abortion is threatened, in progress or incomplete, or may be a sign of ectopic pregnancy or other problem. Signs of incomplete abortion are a soft, enlarged uterus and open cervical os. Abdominal pain frequently precedes or accompanies abortion, postabortion infection and ectopic pregnancy. Severe pain without bleeding may be a sign of ectopic pregnancy.

The treatment of incomplete abortion involves removal of remaining products of conception. This can be safely performed using manual vacuum aspiration (MVA) or other methods. If there are signs of infection, women should be treated with antibiotics (see Chapter 3). All other women should be counselled to come back immediately if any signs of infection appear.

Women with light bleeding and no signs of shock or infection should be further evaluated if they do not improve in the next few days.