›Duration of antibiotics
›Continue IV antibiotics until 24 to 48 hours afebrile and clinically improved after uterine evacuation
›Transition to oral completion after clinical improvement; total course 10 to 14 days
Fulminant infection: Clostridium perfringens and group A streptococcus
›Directed therapy when clostridial myonecrosis is suspected or confirmed
›Penicillin G 4 million units IV every 4 hours
›Combined with clindamycin 900 mg IV every 8 hours for toxin suppression
›Source control (hysterectomy per criteria above) is required in addition to antibiotics; antibiotics alone do not control clostridial myonecrosis
›Directed therapy when invasive group A streptococcal disease is suspected or confirmed
›Penicillin G 4 million units IV every 4 hours plus clindamycin 900 mg IV every 8 hours
›Clindamycin reduces exotoxin production independent of bacterial burden
›Intravenous immunoglobulin has been used as an adjunct for refractory streptococcal toxic shock in case series; evidence is limited and it is not a substitute for source control and antibiotics
›Hemolysis management
›Serial hemoglobin, haptoglobin, LDH, and bilirubin to trend hemolysis
›Packed red blood cell transfusion for hemoglobin < 70 g/L or hemodynamic instability
›Hyperbaric oxygen has been described as an adjunct for clostridial myonecrosis in case reports; it must never delay surgical source control or antibiotics
›Recognize and treat true hyperkalemia from massive hemolysis
›Confirm with ECG (peaked T waves, widened QRS) and repeat non-hemolyzed sample before treating
›Standard emergent hyperkalemia management (calcium, insulin-dextrose, beta-agonist) as for any critical hyperkalemia
Hemodynamic support and vasopressors
›Fluid resuscitation
›Crystalloid 30 mL/kg IV within 3 hours, approximately 2 L in a typical 70 kg adult
›Balanced crystalloid (lactated Ringer's) or normal saline; avoid hydroxyethyl starch
›Reassess after each bolus for fluid responsiveness rather than continuing fixed-volume boluses
›Norepinephrine (first-line vasopressor)
›Starting dose 0.01-0.1 mcg/kg/min IV infusion, titrated every 5-15 minutes to MAP >= 65 mmHg
›Doses up to 1-2 mcg/kg/min may be required in refractory shock
›Can be initiated via peripheral IV (18-20 gauge) for up to 24 hours without delaying for central access
›Vasopressin (second-line addition)
›Fixed dose 0.03 units/min IV infusion, not titrated
›Add when norepinephrine dose >= 0.25-0.5 mcg/kg/min
›Hydrocortisone for refractory vasopressor requirement
›Hydrocortisone 50 mg IV every 6 hours (or 200 mg/day as continuous infusion)
›Indicated when norepinephrine or epinephrine >= 0.25 mcg/kg/min to maintain MAP
›Wean over 24-48 hours when hemodynamically stable; abrupt discontinuation after > 3 days may cause rebound vasodilation
›Vasopressor-refractory shock troubleshooting
›Escalating vasopressor requirement despite completed source control should prompt reassessment for an undrained abscess, uterine necrosis, or wrong antibiotic spectrum rather than further dose escalation alone
Adjunctive therapies: tetanus, Rh prophylaxis, uterotonics, and analgesia
›Tetanus prophylaxis
›Indicated when the antecedent event involved nonsterile or non-medical instrumentation
›Tetanus toxoid-containing vaccine (Td or Tdap) 0.5 mL IM if primary series incomplete, unknown, or last dose more than 10 years prior (more than 5 years for a high-risk wound)
›Tetanus immune globulin (TIG) 250 units IM in addition to vaccine if vaccination history is incomplete or unknown and the wound is high-risk (contaminated instrumentation)
›Rh(D) immune globulin
›Rh(D) immune globulin 50 mcg (300 mcg if gestational age uncertain or the lower dose is unavailable) IM within 72 hours of bleeding onset or procedure for all Rh-negative unsensitized patients
›Uterotonic agents for hemorrhage
›Oxytocin IV 10-40 units in 1 L normal saline at 100-200 mL/hour, titrated to uterine tone and bleeding response
›Methylergonovine 0.2 mg IM
›Contraindicated in hypertension or preeclampsia
›Not for IV bolus; severe vasoconstriction risk
›Misoprostol 800 mcg per rectum as an adjunct if IV access unavailable or bleeding continues after oxytocin
›Analgesia and antipyresis
›Acetaminophen 650-1000 mg PO/IV every 6 hours, maximum 4 g per 24 hours (3 g per 24 hours if hepatic impairment)
›Preferred antipyretic and first-line analgesic; does not impair platelet function
›Ibuprofen 600-800 mg PO every 6-8 hours, maximum 3200 mg per 24 hours
›Relatively avoided in septic shock: NSAID-associated renal risk under hypoperfusion and antiplatelet effect that can worsen bleeding or DIC; if used, use the lowest effective dose for the shortest duration
›Also masks the fever trend used to monitor treatment response
›Opioid analgesia for severe pain
›Fentanyl 25-50 mcg IV every 5-10 minutes titrated, preferred in hemodynamically unstable patients due to relative hemodynamic neutrality
›Morphine 2-4 mg IV every 10-15 minutes titrated as an alternative in hemodynamically stable patients; histamine release can worsen hypotension in shock
Iatrogenic harms of standard ED interventions
›Intubation
›Positive pressure ventilation and induction agents can precipitate hemodynamic collapse in vasodilated septic shock
›Ketamine or etomidate preferred induction agents to minimize further vasodilation; have vasopressor running or immediately available before induction
›Aspiration risk if products of conception or an ongoing pregnancy delay gastric emptying
›Sedation
›Propofol worsens vasodilatory hypotension in septic shock; use reduced doses with vasopressor support available, or avoid in favor of alternative agents
›Fluid loading
›Unlimited crystalloid before source control can dilute coagulation factors, worsen DIC, and cause pulmonary edema without correcting the infected uterus
›Guided, reassessed fluid administration rather than fixed large-volume resuscitation
›Oxygen
›Not contraindicated, but pulse oximetry is unreliable in profound peripheral vasoconstriction; confirm oxygenation with arterial blood gas if in doubt
›Vasopressors
›Vasopressors are supportive only and must not substitute for or delay uterine evacuation
›Escalating vasopressor requirement should trigger reassessment for inadequate source control, not simply a higher dose
›Mechanical circulatory support, including intra-aortic balloon pump
›Contraindicated as primary support in septic (distributive) shock
›IABP is designed for cardiogenic shock with low cardiac output and elevated systemic vascular resistance; septic shock typically has preserved or elevated cardiac output with low systemic vascular resistance, so IABP does not address the underlying physiology
›Consider only if echocardiography confirms a genuine concurrent cardiogenic component (septic cardiomyopathy with severe systolic failure)
›Anticoagulation
›Therapeutic anticoagulation for VTE generally deferred in active hemorrhage, DIC, or platelet count < 50 x 10^9/L
›Prophylactic VTE dosing held if active bleeding or significant coagulopathy; mechanical prophylaxis used instead
›Fibrinolysis
›Systemic fibrinolytics for an unrelated indication (for example massive pulmonary embolism) are relatively or absolutely contraindicated in the days following uterine evacuation or curettage due to hemorrhage risk
›Analgesia
›NSAIDs carry renal and bleeding risk in hypoperfused, coagulopathic patients and mask the fever trend used to monitor response; see Adjunctive therapies for preferred agents
›Morphine's histamine-mediated vasodilation can worsen hypotension in unrecognized septic shock; fentanyl is the hemodynamically preferred opioid
Therapy not working: troubleshooting persistent sepsis
›Persistent fever, lactate, or vasopressor requirement despite evacuation and antibiotics
›Repeat pelvic ultrasound for retained products of conception missed at initial evacuation
›CT abdomen and pelvis for undrained pelvic or tubo-ovarian abscess, uterine perforation, or bowel injury not previously identified
›Septic pelvic thrombophlebitis considered when imaging is negative and fever persists despite adequate antibiotics and completed evacuation
›Diagnosis of exclusion; a trial of therapeutic anticoagulation with defervescence has been described historically to support the diagnosis, but is not a substitute for excluding an abscess first
›Antibiotic spectrum gap
›Confirm anaerobic coverage is present and adequately dosed
›Culture-directed narrowing or broadening based on blood, tissue, or endocervical culture results
›Reconsider clostridial myonecrosis or invasive group A streptococcal disease if deterioration is disproportionate to apparent source control
Safeguarding and unsafe abortion care
›Clinical priority is treatment without judgement
›Provide the same standard of resuscitation, source control, and antibiotics regardless of how the pregnancy loss or termination occurred
›Avoid language or questioning that implies blame; focus history-taking on clinical risk factors (instrumentation, contamination, timing)
›Reporting obligations vary by jurisdiction
›Confirm local legal and institutional requirements before disclosing details of a self-managed or unsafe abortion to any party outside the treating team
›Reporting obligations for minors or suspected coercion, trafficking, or assault follow separate mandatory reporting frameworks distinct from abortion-specific reporting
›Confidential, private assessment for coercion or intimate partner violence
›Interview without accompanying partners or family present when safe to do so