Fatal Clostridium perfringens and Escherichia coli Sepsis Following Urea-Instillation Abortion

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Abstract
Intraamniotic instillation of urea is a common mode of legal second-trimester pregnancy termination. Associated mortality rarely occurs and is most commonly due to amniotic fluid embolism, pulmonary thromboembolism, infection, hemorrhage, and disseminated intravascular coagulation (DIC). We present the case of an 18-year-old gravida 2, para 1 white woman at 18 weeks' gestation who underwent intraamniotic instillation of hyperosmolar urea and intracervical insertion of laminaria tents; 19 h later, she became unresponsive, academic, and went into shock. Coagulation studies were diagnostic of DIC. Bacilli were seen on peripheral blood smear. Autopsy showed marked subcutaneous emphysema of the anterior abdominal wall, necrosis and emphysema of the uterus, diffuse pulmonary alveolar damage, and renal cortical necrosis. Antemortem blood cultures grew Clostridium perfringens and Escherichia coli. Postmortem culture of the uterus grew E. coli. The source of infection was most likely the introduction of vaginal organisms via laminaria insertion. This is apparently the first reported case of death caused by Clostridium perfringens and E. coli sepsis following urea instillation.

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