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Septic incomplete abortion with retained pregnancy tissue — MRCEM SBA MCQ

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HardObstetric and gynaecological emergenciesSeptic incomplete abortion with retained pregnancy tissueMRCEM SBA

A 27-year-old woman attends the emergency department five days after a medical abortion at nine weeks’ gestation. She has increasing lower abdominal pain and offensive vaginal discharge, but only light bleeding. Her temperature is 39.1°C, pulse 128/min and blood pressure 86/52 mmHg; venous lactate is 4.5 mmol/L. Specialist transvaginal ultrasonography shows vascular retained pregnancy tissue within the uterus and no pelvic collection. Blood cultures have been taken, intravenous fluid resuscitation is under way, and gynaecology, anaesthesia and critical care teams are available on site. What is the most appropriate next management plan?

Educational content. Not a substitute for clinical judgement or local policy.

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Correct answer: A — Give intravenous broad-spectrum antibiotics and arrange urgent surgical uterine evacuation.

The combination of fever, offensive discharge and uterine pain after abortion indicates infection; the scan identifies retained tissue as a source requiring control. Hypotension and raised lactate make this a time-critical presentation, not an uncomplicated incomplete abortion. Give intravenous broad-spectrum antibiotics without delay while continuing resuscitation, and arrange urgent surgical uterine evacuation with gynaecology and anaesthesia. RCOG specifically advises urgent evacuation when infection is present, with immediate antibiotics given intravenously for severe infection. NICE advises prompt antimicrobials, fluids and critical care review for a recently pregnant person meeting these high-risk sepsis criteria. ([rcog.org.uk](https://www.rcog.org.uk/media/geify5bx/abortion-care-best-practice-paper-april-2022.pdf)) **B** provides appropriate antibiotics but delays source control until an arbitrary clinical improvement. **C** may attract candidates because misoprostol can treat uncomplicated retained tissue, but it is not the preferred means of urgent evacuation when severe infection is present and surgical care is available. **D** addresses the source but reverses the antibiotic sequence: treatment should begin immediately, not wait until after the procedure. **E** might be reasonable if perforation or another intra-abdominal source were suspected and imaging would change treatment; here, specialist ultrasound has identified the source, so CT would delay definitive care. ([rcog.org.uk](https://www.rcog.org.uk/media/geify5bx/abortion-care-best-practice-paper-april-2022.pdf))

Reference: RCOG, Best practice in abortion care — Management of incomplete abortion (2022) — https://www.rcog.org.uk/media/geify5bx/abortion-care-best-practice-paper-april-2022.pdf NICE NG255, Suspected sepsis in pregnant or recently pregnant people — Managing suspected sepsis (19 November 2025) — https://www.nice.org.uk/guidance/NG255/chapter/managing-suspected-sepsis