A 34-year old woman, gravida 2, para 1, at 14 weeks gestation presented with severe, crampy, lower abdominal pain, nausea,

vomiting and anorexia. There was no report of ruptured membrane or illness prior to presentation. On review of systems, she denied any fever, chills, cough, ear pain, dysuria or headaches.

In the emergency room, she was found to have a fever of 39.2C and developed vaginal bleeding. Physical examination was significant for diffuse abdominal tenderness over bilateral lower abdominal quadrants, right greater than left. There was no neck stiffness, sinus tenderness, or crackles on lung examination. Ear examination was normal.

Laboratory results showed A white blood cell count of 23, 200 per mm3 with a neutrophil predominance normal liver function test, urinalysis, and electrolytes A vaginal ultrasound showed intrauterine pregnancy at 12 weeks gestation.

The patient was started on piperacillin-tazobactam for broad antibiotic coverage given the unclear source of infection. On hospital day 2, her symptoms were much improved, though she continued to have fever of 38.6C with a white blood cell count of 300,500 per mm3 . The patient subsequently passed tissue later that day with a vaginal ultrasound showing abortion in progress.

She then underwent dilatation and curettage for incomplete septic abortion. Subsequently, her fever lyzed, had resolution of her abdominal pain and no further signs of infection. Blood and placenta cultures came back positive for penicillin-sensitive Streptococcus pneumoniae.

The patients antibiotic was changed to penicillin, and she was discharged home to complete a 14-day course of therapy. On her 2-week hospital follow-up, she remained well, with no complaints of fever or any other signs of infection.

To discuss
The risk factors in Septic Abortion The complications of Septic Abortion The immune defenses of the body and major components of each system The factors which participate in the generation of fever

A septic abortion is an abortion associated with an infection inside a pregnant woman's uterus. The infection can occur during or just before or after an abortion.

Spontaneous abortion which is referred to as a miscarriage. Elective surgical or medical abortion meaning the woman chose to terminate her pregnancy

Type of Abortion Spontaneous Abortion

Description This is when the abortion occurs naturally as opposed to being induced. The pregnancy is terminated artificially. There is bleeding and sometimes pelvic pain but the cervix is closed and ultrasound indicates an ongoing pregnancy within the uterus. The pregnancy is not continuing. An inevitable abortion and the uterus has completely emptied itself. An inevitable abortion with products of the pregnancy still present in the uterus. There are no reasons to have suspected that the pregnancy is not going to continue but the embryo has died. The abortion has been complicated by infection. Most authorities recommend that these terms should be used only for three or more consecutive abortions although there is a tendency towards two. Abortion in the first few weeks of the pregnancy. Abortion after the first few weeks. Abortion before thirteen weeks of pregnancy. Abortion after thirteen weeks and before twenty four weeks.

Induced Abortion Threatened Abortion

Inevitable Abortion Complete Abortion

Incomplete Abortion

Missed Abortion

Septic Abortion Recurrent or habitual Abortion

Early Abortion Late Abortion First trimester Abortion Second trimester Abortion

The fetal membranes surrounding the unborn child have ruptured, sometimes without being detected The woman has a sexually transmitted infection such as chlamydia
An intrauterine device (IUD) was left in place during the pregnancy Tissue from the unborn child or placenta is left inside the uterus after a miscarriage

Unsafe abortion was made to end the pregnancy

Insertion of tools, chemicals, or soaps into the uterus

How is the condition diagnosed?

diagnostic criteria: a) temperature of 38C (100.4F) of at least 24 hours duration not due to other causes b) history of mechanical termination c) presence of septic cervical discharge d) presence of uterine, parametrial or adnexal tenderness

Diagnostics Tests:

CBC, or complete blood count

pregnancy ultrasound cultures of blood or uterine contents Blood chemistry

-Vaginal Bleeding *May be accompanied by hypolvolemia -Septic Shock *Caused by release of toxins by organisms such as E.Coli, Klebsiella, Proteus etc. *Warm extremities and hypotension -Abcess *Massive pelvic and abdominal abscesses -pouch of Douglas *Accompanied by high fever, abdominal cramps and reduced bowel sounds -Acute Renal Failure *Urinary output < 30mls per hour despite adequate hydration and blood transfusion adequate hydration -Death

Merida Mirabel Monghit

What are the immune defenses of the body? Major components of each system.

Immune System
Innate Immunity (Non-specific or Natural)

Acquired Immunity (Specific or Adaptive)

Innate Immunity
Immunity that occurs naturally as a result of a person's genetic constitution or physiology and does not arise from a previous infection or vaccination. Also called genetic immunity, inherent immunity, native immunity, natural immunity, nonspecific immunity.

Innate Immunity
no need for prolonged induction act quickly immediate direct response 0-4 hrs rapid induced 4-96 hrs failure ==> adaptive immune response Pathogen recognized by receptors encoded in the germline: pattern recognition receptors Receptors have broad specificity, i.e., recognize many related molecular structures called PAMPs (pathogenassociated molecular patterns) No memory of prior exposure

Component of Innate Immunity

1st Line of Defense
Mechanical Barriers Chemical & Biochemical Inhibitors Biological Barriers

2nd Line of Defense

Cellular Components Soluble Factors Inflammatory Barriers

1st Line: Mechanical Barriers

Intact skin Mucous coat Mucous secretion Blinking reflex and tears The hair at the nares Coughing and sneezing reflex

1st Line: Chemical Inhibitors

Sweat and sebaceous secretion Hydrolytic enzymes (saliva) HCl (stomach) Proteolytic enzyme (small intestine) Lysozyme (tears) Acidic pH (adult vagina)

nd 2

Line: Cellular Components

Phagocytes
Neutrophils Macrophages Dendritic Cells Natural Killer Cells Mast Cells Basophils Eosinophils

2nd Line: Soluble Factors

Complement Interferons () Properdins Beta Lysine Lactoferrin, Transferrin Lactoperoxidase Lysozyme

2nd Line: Complement System

2nd Line: Inflammatory Barriers

Release of chemical mediators
(Histamine, fibrin, kinins, cytokines)

Vasodilation of capillaries

Immunity

Acquired Immunity

Innate Immunity

Humoral

Cellmediated

B-cell immunity

B-cell immunity
B Lymphocyte T lymphocyte Preprocessed in Thymus Gland Liver and Bone Marrow B lymphocyte + T lymphocyte itself antibodies (reactive agent) More diverse millions of types of antibodies

After Preprocessing

Lymphoid Tissue

also called immunoglobulins are proteins manufactured by the body that help fight against foreign substances called antigens When an antigen enters the body, it stimulates the immune system to produce antibodies.

IgM IgG IgA IgD

Complement activation Complement activation

Localized protection in external secretions Antigen recognition by B cells Reagin activity; releases histamine from basophils and mast cells

IgE

1.Direct attack 2.Activation of the Complement System

1. Agglutination 2. Precipitation 3.Neutralization 4.Lysis

Cell-Mediated Immunity
Second type of acquired immunity formation of large numbers of activated T lymphocytes that are specifically crafted in the lymph nodes to destroy the foreign agent

T Lymphocytes
Preprocessed in the thymus Some of the T cells (helper cells) activate specific B lymphocytes Upon exposure to antigen, T lymphocytes proliferate and release large numbers of activated, specifically reacting T cells

 T lymphocyte memory cells are formed in the same way that B memory cells are formed in the antibody system Subsequent exposure to the same antigen produces a more rapid release of activated T cells

 T-cell responses are extremely antigen specific three major types of antigenpresenting cells:
Macrophages B lymphocytes dendritic cells

Types of T Cells
Helper T Cells Cytotoxic T Cells Suppressor T Cells

Allergy and Hypersensitivity

An important undesirable side effect of immunity

Streptococcus pneumoniae
not a normal inhabitant of the vaginal flora
does not survive in its acidic pH
pH could be alkalinized from the rupture of the membranes allow S. pneumoniae to thrive in the vagina

appeared to be the cause of chorioamnionitis and premature rupture of the membranes

 Physiologic changes in the lower genital tract:

decreased in pH Increased glycogen in the vaginal epithelium
place the pregnant woman at risk for intra-amniotic infection

 The most common route: ascending infection from one or more of the endogenous flora of the cervix or vagina
The most frequent causative pathogens are Aerobic Bacteria

 intraamniotic infection
spontaneous rupture of membranes weakening the membranes
direct effect of microorganisms on the membranes indirectly by activation of the host defense mechanisms

produce an enterotoxin that transfers into the bloodstream

provoking the overstimulation of the immune system

Recommended

Alternative

Penicillin G, 5 million units IV initial dose, then 2.5 million units IV every 4 hours until delivery Ampicillin, 2 g IV initial dose, then 1 g IV every 4 hours or 2 g every 6 hours until delivery

If penicillin allergica Patients not at high risk for Cefazolin, 2 g IV initial dose, then 1 g anaphylaxis IV every 8 hours until delivery

Patients at high risk for anaphylaxis and with GBS susceptible to clindamycin and erythromycin

Clindamycin, 900 mg IV every 8 hours until delivery OR Erythromycin, 500 mg IV every 6 hours until delivery GBS resistant to clindamycin Vancomycin, 1 g IV every 12 hours or erythromycin or until delivery susceptibility unknown

Fever, which means a body temperature above the usual range of normal, can be caused by abnormalities in the brain itself or by toxic substances that affect the temperature-regulating centers.

 Many proteins, breakdown products of proteins, and certain other substances, especially lipopolysaccharide toxins released from bacterial cell membranes, can cause the setpoint of the hypothalamic thermostat to rise. Substances that cause this effect are called pyrogens.

 Pyrogens released from toxic bacteria or those released from degenerating body tissues cause fever during disease conditions. When the set-point of the hypothalamic temperatureregulating center becomes higher than normal, all the mechanisms for raising the body temperature are brought into play, including heat conservation and increased heat production.

 When bacteria or breakdown products of bacteria are present in the tissues or in the blood, they are phagocytized by the blood leukocytes, by tissue macrophages, and by large granular killer lymphocytes. All these cells digest the bacterial products and then release the substance interleukin-1also called leukocyte pyrogen or endogenous pyrogeninto the body fluids.