INTRODUCTION — Septic abortion refers to any abortion, spontaneous or induced, that is complicated by uterine infection, including endometritis. Septic abortion typically refers to pregnancies of less than 20 weeks gestation while those ≥20 weeks gestation with intrauterine infection are described as having intraamniotic infection.

This topic will discuss the clinical presentation, evaluation, and management of patients with septic abortion. Management of related uterine infections, including intraamniotic infection, postpartum endometritis, and pelvic inflammatory disease, are discussed elsewhere.

●(See "Intraamniotic infection (clinical chorioamnionitis)".)

●(See "Postpartum endometritis".)

●(See "Pelvic inflammatory disease: Treatment in adults and adolescents".)

In this topic, when discussing study results, we will use the terms "women" or "patients" as they are used in the studies presented. However, we recognize that not all individuals capable of pregnancy identify as women, and we encourage the reader to consider the specific counseling and treatment needs of transgender and gender diverse individuals.

EPIDEMIOLOGY AND MICROBIOLOGY

●Incidence – The incidence of septic abortion is not fully known as it encompasses infection following both spontaneous pregnancy loss and pregnancy termination (medication and surgical). The data are further confounded by varying definitions of infection across studies and contemporary use of preoperative antibiotics prior to uterine aspiration procedures. In a systematic review of office-based first-trimester termination with uterine aspiration, infections requiring intravenous (IV) antibiotics occurred in 0 to 0.4 percent of patients [1]. (See "First-trimester pregnancy termination: Uterine aspiration", section on 'Antibiotic prophylaxis'.)

●Microbiology – Vaginal bacteria that gain access to the uterine cavity can invade the placenta, endometrium, myometrium, and beyond. Routine vaginal flora and anaerobic pathogens are typical [2-5]. In one study of 84 individuals with an infected abortion, the most commonly identified organisms were Enterobacteriaceae (35 percent), streptococci (31 percent), staphylococci (9 percent), and enterococci (9 percent) [6]. Group A Streptococcus infections can develop and progress rapidly in postpartum individuals. (See "Pregnancy-related group A streptococcal infection".)

CLINICAL FEATURES

Presenting scenarios — Septic abortion can occur after both induced and spontaneous abortion (ie, pregnancy loss or miscarriage).

●Pregnancy loss – Individuals in various states of pregnancy loss can develop intrauterine infection. These include those with a nonviable intrauterine pregnancy, a partially passed non-viable pregnancy (ie, incomplete abortion), or completed pregnancy loss with an infected uterus, often related to retained products of conception. Individuals with complications of early pregnancy loss may not know that they are, or recently have been, pregnant. (See "Pregnancy loss (miscarriage): Clinical presentations, diagnosis, and initial evaluation", section on 'Complicated (hemorrhage and/or infection)'.)

●Pregnancy termination – Intrauterine infection is a potential complication of both medication and surgical pregnancy termination. Infection can result from a procedure or be associated with retained products of conception. To reduce the risk of infection, individuals undergoing surgical abortion with uterine aspiration receive a dose of preoperative antibiotics; infection rates are below 1 percent with this approach. However, unsafe pregnancy termination procedures continue to occur globally and have a much higher rate of morbidity and mortality.

•(See "First-trimester pregnancy termination: Uterine aspiration", section on 'Antibiotic prophylaxis'.)

•(See "Second-trimester pregnancy termination: Dilation and evacuation", section on 'Prophylactic antibiotics'.)

Signs and symptoms

●Common signs and symptoms – These typically include pelvic and/or abdominal pain, uterine tenderness, purulent vaginal discharge, vaginal bleeding, and/or fever. Vaginal bleeding may be recent or active, depending on whether the pregnancy has already passed.

●Severe infection and sepsis – As the name septic abortion implies, those with uterine infection can progress to severe infection that triggers life-threatening organ dysfunction caused by a dysregulated host response to infection. Markers of severe infection include fever (>38.0°C) or hypothermia, tachypnea, tachycardia, and leukocytosis or leukopenia (table 1). (See "Sepsis syndromes in adults: Epidemiology, definitions, clinical presentation, diagnosis, and prognosis", section on 'Clinical presentation'.)

EVALUATION

Need for rapid recognition — Septic abortion can progress rapidly and be lethal. Therefore, any patient who presents with abdominal/pelvic pain, uterine tenderness, and fever in the setting of pregnancy loss or recent pregnancy should be evaluated quickly (algorithm 1). Individuals at particular risk for septic abortion include those with a history of unsafe abortion, uterine instrumentation, or prolonged vaginal bleeding [7]. Once recognized, the general approach includes empiric broad-spectrum intravenous (IV) antibiotics, IV fluid support, and surgical evacuation of the uterus (regardless of fetal heart rate activity) [3-5,8]; the speed and intensity of response vary with the hemodynamic stability of the patient, as discussed below. (See 'Management' below.)

Obtain targeted history — Patients presenting with infection in the setting of pregnancy loss may not be aware that they are or have recently been pregnant (eg, early pregnancy loss may be experienced as a late period). Additionally, some may have tried to interrupt the pregnancy without involving a medical professional or using unsafe methods. In addition to asking about medical conditions, medications, and allergies, additional questions include:

●Date of last menstrual period and whether or not the patient has regular periods (ie, approximately monthly). Individuals with irregular menses, such as those with polycystic ovary syndrome, may be less likely to know they are pregnant.

●If the patient is known to be pregnant.

●If the patient had a uterine procedure within a few weeks of presentation.

Perform laboratory evaluation — We perform the following studies for patients with septic abortion (algorithm 1):

●Blood cultures – Blood cultures, both aerobic and anaerobic, to assess for bacteremia. We typically limit drawing blood cultures to patients presenting with fever or if there is clinical concern for bacteremia. Patients with bacteremia require longer courses of antibiotic therapy compared with those with local uterine infection.

•(See "Detection of bacteremia: Blood cultures and other diagnostic tests".)

•(See "Gram-negative bacillary bacteremia in adults", section on 'Management'.)

●STI screen – Test for sexually transmitted infections (STI), including gonorrhea, Chlamydia trachomatis, and trichomoniasis, which are risk factors for uterine infection. STI screening can be performed on urine, vaginal, or cervical specimens. (See "Screening for sexually transmitted infections", section on 'Screening methods'.)

●Serum tests for sepsis syndromes – Serum tests to evaluate for sepsis syndromes, including complete blood count with differential, lactate level, coagulation studies (prothrombin time/partial thromboplastin time and fibrinogen), and a complete metabolic panel (to evaluate renal function). (See "Sepsis syndromes in adults: Epidemiology, definitions, clinical presentation, diagnosis, and prognosis", section on 'Laboratory signs'.)

●Blood type and antibody screen – These are performed in case transfusion is needed. (See "Pretransfusion testing for red blood cell transfusion".)

●Urinalysis and urine culture – These are useful to exclude urinary tract infection and/or pyelonephritis. (See "Acute simple cystitis in women", section on 'Clinical suspicion and evaluation'.)

Assess for complications of septic abortion — Complications of septic abortion include acute respiratory distress syndrome (ARDS), hemolysis and/or disseminated intravascular coagulation (DIC), lactic acidosis, acute renal injury, and sepsis syndromes. Patients who are diagnosed with any of these may rapidly progress to hemodynamic instability and are thus managed as an emergency situation and moved toward rapid surgical treatment as quickly as medically safe.

●(See "Acute respiratory distress syndrome: Clinical features, diagnosis, and complications in adults".)

●(See "Evaluation and management of disseminated intravascular coagulation (DIC) in adults".)

●(See "Causes of lactic acidosis", section on 'Type A lactic acidosis'.)

●(See "Nonoliguric versus oliguric acute kidney injury".)

●(See "Sepsis syndromes in adults: Epidemiology, definitions, clinical presentation, diagnosis, and prognosis", section on 'Definitions'.)

Proceed with imaging if clinically stable

Role of ultrasound to aid clinical decision-making — While ultrasound can be useful to confirm pregnancy loss and evaluate the uterus, the decision to treat with antibiotics and evacuate the uterus is based on the patient's history and evaluation findings. Ultrasound can aid in the diagnosis by demonstrating retained products of conception, but normal ultrasound imaging does not exclude septic abortion. Ultrasound measurement of endometrial thickness by itself does not predict need for surgical intervention [9].

Common ultrasound findings — While ultrasound findings are not diagnostic for septic abortion, ultrasound imaging can be useful to identify frank pregnancy-related tissue (if present) or identify evidence of upper tract infection (eg, dilated fallopian tubes and/or tubo-ovarian abscess) [10].

Information that is commonly obtained from ultrasound imaging includes:

●Presence or absence of embryo or fetal tissues.

●Gestational age and presence/absence of a heartbeat (if embryo or fetus is seen). The presence of a viable fetus on ultrasound imaging does not exclude the possibility of septic abortion nor does it change the interventions needed to treat a patient with sepsis.

●Amount of intrauterine tissue (in three planes). If present, intrauterine tissue is evaluated for blood flow.

●Enhanced myometrial vascularity. Postpartum patients may have increased myometrial vascularity even in the absence of endometrial tissue, which can help support the diagnosis of recent pregnancy, and suggest septic abortion, if the history is unclear.

●Hydrosalpinges or adnexal mass suggestive of abscess.

Computed tomography — For hemodynamically stable patients in whom appendicitis or intra-abdominal abscess, such as from diverticulitis, is a concern, evaluation with computed tomography (CT scan) may be helpful. (See "Acute appendicitis in adults: Diagnostic evaluation", section on 'Imaging'.)

DIAGNOSIS — Septic abortion is a clinical diagnosis made in patients who present with signs and symptoms of uterine infection (uterine pain and tenderness, fever, vaginal bleeding) following pregnancy loss or termination up to 20 weeks gestation.

DIFFERENTIAL DIAGNOSIS — Other common causes of abdominal/pelvic pain and fever in pregnant or recently pregnancy individuals include (but are not limited to) postpartum endometritis, urinary tract infection, pyelonephritis, and appendicitis [7].

•Postpartum endometritis – These individuals present with uterine pain and tenderness, fever, and related symptoms (nausea, fatigue) following delivery at 20 weeks gestation or greater. (See "Postpartum endometritis".)

•Urinary tract infection with or without pyelonephritis – Individuals with urinary tract infections often have pain with urination, urinary frequency, and urinary urgency in addition to pelvic pain and/or tenderness. Additional findings suggestive of upper tract infection include flank pain and fever. The urinary symptoms and abnormal urinalysis differentiate urinary tract infection from septic abortion.

-(See "Acute simple cystitis in women".)

-(See "Acute complicated urinary tract infection (including pyelonephritis) in adults".)

•Appendicitis – Appendicitis classically presents with right lower quadrant abdominal pain, lack of appetite (anorexia), and nausea and vomiting. Pelvic pain, tenderness, and low-grade fever may also be present, but the uterus itself is not tender in patients with appendicitis. (See "Acute appendicitis in adults: Clinical manifestations and differential diagnosis".)

MANAGEMENT — Management of individuals with septic abortion includes rapid recognition of infection, initiation of broad-spectrum antibiotics and intravenous (IV) fluid, and removal of infected intrauterine tissue (algorithm 1) [8]. The urgency of these steps varies with the severity of the patient's presentation and hemodynamic stability.

Hemodynamically unstable patient — Patients who are hemodynamically unstable require emergency resuscitation (including vasopressors and inotropes as needed), initiation of IV antibiotics, and urgent surgical evacuation of the uterus. While these components are the same as for stable individuals, hemodynamically unstable individuals have the steps performed in rapid sequence so that surgical uterine evacuation can occur as quickly as possible to facilitate resuscitation. (See "Evaluation and management of suspected sepsis and septic shock in adults", section on 'Initial resuscitative therapy'.)

●Resuscitation in an operative setting may aid the process.

●Patients with suspected infection with toxin-producing bacteria or uterine injury may require emergency progression to exploratory laparotomy and hysterectomy.

●Postoperative management in an intensive care unit may be required.

Stable patient — The cornerstones of treatment are the rapid restoration of perfusion, initiation of IV antibiotics, and surgical evacuation of the uterus (algorithm 1). The patient may require management in the emergency department or operating room setting to maximize resuscitation.

Begin intravenous fluids — Intravascular hypovolemia may be present, particularly in individuals with prolonged bleeding and/or evidence of sepsis syndrome, and rapid fluid resuscitation is warranted. One data-supported approach is rapid infusion of crystalloid fluid boluses of 30 mL/kg during the first one to three hours of resuscitation (assuming there is no evidence of pulmonary edema) [11-13]. Additional discussions of fluid selection, volume, and timing are presented separately. (See "Evaluation and management of suspected sepsis and septic shock in adults", section on 'Intravenous fluids (first three hours)'.)

Start broad-spectrum intravenous antibiotics — For patients with septic abortion, we initiate broad-spectrum IV antibiotics [7]. The regimen is selected empirically, as a specific pathogen is rarely if ever known at the time of presentation. Most infections arise from vaginal flora and include anaerobic pathogens. (See 'Epidemiology and microbiology' above.)

Commonly used regimens — While the authors prefer the first regimen listed below, all are reasonable. Selection is based on patient allergies, drug availability, and cost. In a study of 84 patients with septic abortion, the combination of intravenous ampicillin, gentamicin, and metronidazole had the highest laboratory susceptibility results while piperacillin-tazobactam provided greatest single-agent microbial coverage [6,7]. Patients with suspected toxin-producing infection or group A Streptococcus benefit from inclusion of clindamycin in their treatment regimen [14,15]. Antibiotic coverage is tailored once culture results are available.

●Gentamicin (5 mg/kg/day IV) plus ampicillin (2 g IV every four hours) plus clindamycin (900 mg IV every eight hours)

or

●Gentamicin (5 mg/kg/day IV) plus ampicillin (2 g IV every four hours) plus metronidazole (500 mg IV every eight hours)

or

●Levofloxacin (500 mg IV daily) and metronidazole (500 mg IV every eight hours)

or

●Imipenem (500 mg IV every six hours)

or

●Piperacillin-tazobactam (4.5 g IV every eight hours)

or

●Ticarcillin-clavulanate (3.1 g IV every four hours)

Alternative regimens — Based on the Centers for Disease Control and Prevention (CDC) Sexually Transmitted Diseases Treatment Guidelines' suggested drug treatment of pelvic inflammatory disease, regimens consisting of cefoxitin or cefotetan, plus doxycycline and metronidazole, could also be reasonable, although these agents have not been specifically studied for septic abortion [16,17].

Oral regimens — In general, we do not use oral antibiotics for initial treatment of septic abortion because of insufficient data on efficacy and safety. (See "Pelvic inflammatory disease: Treatment in adults and adolescents".)

Evacuate the uterus — Patients with clinically symptomatic infection, even those who do not meet criteria for sepsis syndrome, require urgent surgical evacuation of the uterus (algorithm 1). Expectant or medication management of retained uterine tissue is generally not advised because of the potentially life-threatening nature of septic abortion [18,19]. Uterine evacuation by aspiration is typically performed after initiation of IV antibiotics. While evidence-based consensus is lacking, we advise evacuation within four to six hours after presentation, once antibiotics and fluids have been initiated and the patient is stabilized.

●Technique – The technique for uterine aspiration is the same whether the patient experienced pregnancy loss or a complication of induced abortion. Gestational age of the pregnancy, if still present, generally guides the approach. As with all uterine aspiration procedures in the first trimester, we avoid sharp curettage [20,21]. Additional discussion of surgical management is presented in related content. (See "Pregnancy loss (miscarriage): Management techniques", section on 'Surgical management (uterine aspiration)'.)

●Ultrasound guidance – The authors use ultrasound guidance during the procedure to ensure all infected tissue is removed and to potentially reduce the risk of uterine perforation, which is more likely in an infected uterus. However, the procedure should not be delayed if an ultrasound is not immediately available. [20,21].

●Culture of retained tissue – Pregnancy tissue (products of conception) should be sent for aerobic and anaerobic culture as this may guide subsequent antibiotic choice. Culture of the uterus cavity is not indicated. (See "Pregnancy loss (miscarriage): Management techniques", section on 'Surgical management (uterine aspiration)'.)

●Risks – In the presence of infection, the main risks of uterine evacuation are bleeding, which can be massive, and uterine perforation.

•Massive hemorrhage – Massive hemorrhage can occur with uterine atony or vascular injury. (See "Massive blood transfusion".)

•Uterine perforation – Perforation can lead to injury of abdominal or pelvic organs or vasculature. (See "Uterine perforation during gynecologic procedures".)

Postoperative care — Postoperatively, patients with septic abortion require frequent monitoring and ongoing management (algorithm 2).

Frequent monitoring — After uterine aspiration, the patient continues IV antibiotics and fluid. We monitor patients continuously and reassess them hourly for improvement or lack thereof. Evidence of clinical improvement can be seen as early as six hours after uterine evacuation combined with IV fluid resuscitation and antibiotics [22].

Patients who improve — Patients who improve are transitioned to routine postoperative care protocols, and IV antibiotics are tailored to the culture results (algorithm 2). If the culture does not identify specific organisms, then broad-spectrum regimens that include coverage of anaerobic organisms are maintained. Intravenous antibiotics are continued until the patient has clinical evidence of resolving infection (eg, afebrile for 48 hours, reduced pelvic tenderness); the patient is then transitioned to oral antibiotics to complete a 10- to 14-day course. One oral antibiotic regimen that is extrapolated from treatment of patients with pelvic inflammatory disease includes [16]:

●Doxycycline 100 mg orally twice a day for 14 days

and

●Metronidazole 500 mg orally twice a day for 14 days

Patients who do not improve or who worsen — Following uterine aspiration, patients who do not adequately improve and/or who develop sepsis syndrome, acute respiratory distress syndrome (ARDS), disseminated intravascular coagulation (DIC), evidence of organ failure, peritonitis, or pelvic abscess proceed with emergency laparotomy and hysterectomy (algorithm 2) [7]. IV antibiotics and fluid resuscitation are continued. If readily available, abdominal imaging with radiograph or computed tomography (CT) can be helpful to assess for free air in the abdomen and/or gas in the myometrium, which suggest clostridial infection. This is a devastating disease progression and by definition, is occurring in young, reproductive-age women. A desire to preserve future fertility should not prevent performing a life-saving hysterectomy.

●(See "Sepsis syndromes in adults: Epidemiology, definitions, clinical presentation, diagnosis, and prognosis", section on 'Clinical presentation'.)

●(See "Acute respiratory distress syndrome: Clinical features, diagnosis, and complications in adults".)

●(See "Evaluation and management of disseminated intravascular coagulation (DIC) in adults".)

●(See "Causes of lactic acidosis", section on 'Type A lactic acidosis'.)

●(See "Nonoliguric versus oliguric acute kidney injury".)

EXPLORATORY LAPAROTOMY AND HYSTERECTOMY — Emergency laparotomy and hysterectomy may be necessary to treat infection that does not respond (or spreads) or complications of uterine evacuation.

Specific scenarios include:

●Infection with toxin-producing bacteria – These include group A Streptococcus, Clostridioides (formerly Clostridium) species, and strains of Escherichia coli. Such infection can be confirmed by culture or suggested by imaging studies showing gas in tissues or the physical examination finding of crepitance.

•(See "Clostridial myonecrosis" and "Clostridial myonecrosis", section on 'Treatment'.)

•(See "Pregnancy-related group A streptococcal infection", section on 'Surgery'.)

●Evidence of myonecrosis – Hysterectomy is required for an avascular wood-like uterus because antibiotics cannot penetrate necrotic tissue.

•(See "Surgical management of necrotizing soft tissue infections".)

●Significant intraperitoneal infection – This can include tubo-ovarian or other abscess(es).

•(See "Management and complications of tubo-ovarian abscess".)

●Massive hemorrhage – Hysterectomy can be a life-saving procedure for massive bleeding from vascular injury (uterus or pelvic vessels), uterine atony, or coagulopathy.

•(See "Massive blood transfusion".)

●Perforation or rupture of the uterus – These can result from uterine instrumentation or delivery.

•(See "Uterine perforation during gynecologic procedures", section on 'Abdominal exploration'.)

SOCIETY GUIDELINE LINKS — Links to society and government-sponsored guidelines from selected countries and regions around the world are provided separately. (See "Society guideline links: Pregnancy loss (spontaneous abortion)" and "Society guideline links: Pregnancy termination".)

INFORMATION FOR PATIENTS — UpToDate offers two types of patient education materials, "The Basics" and "Beyond the Basics." The Basics patient education pieces are written in plain language, at the 5^th to 6^th grade reading level, and they answer the four or five key questions a patient might have about a given condition. These articles are best for patients who want a general overview and who prefer short, easy-to-read materials. Beyond the Basics patient education pieces are longer, more sophisticated, and more detailed. These articles are written at the 10^th to 12^th grade reading level and are best for patients who want in-depth information and are comfortable with some medical jargon.

Here are the patient education articles that are relevant to this topic. We encourage you to print or e-mail these topics to your patients. (You can also locate patient education articles on a variety of subjects by searching on "patient info" and the keyword(s) of interest.)

●Basics topics (see "Patient education: Miscarriage (The Basics)" and "Patient education: Bleeding in early pregnancy (The Basics)" and "Patient education: Abortion (The Basics)")

●Beyond the Basics topics (see "Patient education: Miscarriage (Beyond the Basics)" and "Patient education: Abortion (pregnancy termination) (Beyond the Basics)")

SUMMARY AND RECOMMENDATIONS

●Clinical presentation and diagnosis – Septic abortion is a clinical diagnosis made in patients who present with signs and symptoms of uterine infection, including abdominal or pelvic pain, uterine tenderness, purulent vaginal discharge, vaginal bleeding, and/or fever following pregnancy loss or termination. The incidence of septic abortion is not fully known as it encompasses infection following both spontaneous pregnancy loss and pregnancy termination (medication and surgical). Most infections arise from vaginal flora and include anaerobic pathogens. (See 'Signs and symptoms' above and 'Diagnosis' above and 'Epidemiology and microbiology' above.)

●Evaluation – Septic abortion can progress rapidly and be lethal. Therefore, any patient who presents with abdominal/pelvic pain, uterine tenderness, and fever in the setting of pregnancy loss or recent pregnancy should be evaluated quickly with a targeted history, including discussion of last menstrual period, laboratory evaluation, and ultrasound imaging (algorithm 1). (See 'Evaluation' above.)

●Management – The cornerstones of treatment are the rapid restoration of perfusion with intravenous (IV) fluid, initiation of IV antibiotics, and surgical evacuation of the uterus (algorithm 1). (See 'Management' above.)

•Hemodynamically unstable patients – Patients who are hemodynamically unstable require emergency resuscitation and often benefit from simultaneous evaluation and treatment in an intensive care or operative setting. While the treatment components are the same as presented for stable individuals below, the steps are performed simultaneously and in an emergency fashion so that surgical uterine evacuation can occur as quickly as possible. (See 'Hemodynamically unstable patient' above and "Evaluation and management of suspected sepsis and septic shock in adults", section on 'Immediate evaluation and management'.)

•Stable patients

-Intravenous fluid – Intravascular hypovolemia may be present, particularly in individuals with prolonged bleeding and/or evidence of sepsis syndrome, and rapid fluid resuscitation is required. There is no single approach to fluid choice or infused volume; treatment is tailored to the clinical status of the patient. (See 'Begin intravenous fluids' above and "Evaluation and management of suspected sepsis and septic shock in adults", section on 'Intravenous fluids (first three hours)'.)

-Broad-spectrum intravenous antibiotics – Prompt antimicrobial therapy is required for the treatment of septic abortion. For most patients with septic abortion in which the pathogen is unknown, we suggest empiric treatment with gentamicin plus ampicillin plus clindamycin rather than other regimens (Grade 2C). However, alternative regimens are reasonable and selected based on patient allergies, drug availability, and cost. Antibiotic coverage may be tailored pending culture results. (See 'Commonly used regimens' above.)

-Surgical uterine evacuation – Patients with clinically symptomatic infection, even those who do not meet criteria for sepsis syndrome, require urgent surgical evacuation of the uterus. The authors use ultrasound guidance during the procedure to ensure all infected tissue is removed and to potentially reduce the risk of uterine perforation, which is more likely in the setting of infection. Expectant or medication management of retained uterine tissue is generally not advised because of the potentially life-threatening nature of septic abortion. (See 'Evacuate the uterus' above.)

●Postoperative care – After uterine aspiration, the patient continues IV antibiotics and fluid. We monitor patients continuously and reassess them hourly for improvement or lack thereof (algorithm 2). (See 'Postoperative care' above.)

•Adequate improvement – Patients who improve are moved to routine postoperative care protocols (algorithm 2). Antibiotic therapy is tailored based on culture results and clinical response. (See 'Patients who improve' above.)

•Inadequate improvement or clinical worsening – Patients who do not adequately improve and/or who develop sepsis syndrome, acute respiratory distress syndrome (ARDS), disseminated intravascular coagulation (DIC), evidence of organ failure, peritonitis, or pelvic abscess proceed to laparotomy with possible hysterectomy (algorithm 2). (See 'Patients who do not improve or who worsen' above.)

●Laparotomy and/or hysterectomy – Clinical scenarios that warrant laparotomy include concern for extensive infection/abscess, severe vascular injury (uterus or pelvic vessels), and massive hemorrhage from uterine atony or coagulopathy. Hysterectomy is done as a life-saving procedure for either bleeding and/or infection. (See 'Exploratory laparotomy and hysterectomy' above.)

ACKNOWLEDGMENTS — The UpToDate editorial staff acknowledges Togas Tulandi, MD, MHCM, and Haya M Al-Fozan, MD, who contributed to an earlier version of this topic review.