Med. J. Malaysia Vol. 45 No.

4 December 1990

Tetanus after induced abortion

Summary
A case of tetanus occurring after induced abortion is reported. The patient gave a history of low
grade fever with chill and rigors, headache, neck pain and Trismus. She subsequently developed
respiratory distress. However, incorrect information from the patient resulted in the delay to
locate and eradicate the source of infection. Early referral to an intensive care unit for ventilatory
assistance was the most appropriate step to save the patient. Complications which occurred during
the course of the disease were sometimes difficult to overcome. These complications were
probably related to the duration of stay in the intensive ~are unit. Their incidence could be
reduced by more meticulous patient care.

Key words: Tetanus, induced septic abortion.

Introduction
Tetanus is an acute, often fatal disease caused by an extremely potent neurotoxin produced by
Clostridium tetani 1 ,2,3. This organism is ubiquitous and its occurrence in nature cannot be
controlled. The disease still represents a serious health problem in developing countries and still
carries high morbidity and mortality 2,4,5,6. This high morbidity and mortality have been related
to the lack of specific therapeutic measures and orderly intensive. patient care plans. Immunisation
is highly effective, provides long lasting protection and is recommended for the whole
population 2 ,3, 7 ,8. Tetanus usually occur as a complication of minor trauma. 2 ,3 It results from
direct innoculation with Clostridium tetani, an anaerobic Gram-positive bacillus. The spores are
found in faeces and dust especially in hot damp climates and in soil rich in organic matter.
However tetanus may follow elective and emergency surgical procedures. 3 Tetanus has been
reported as a complication by gynaecological surgery,9 dental procedures 10 and a number. of
gastrointestinal operations!! -1 7. Systemic manifestations of the infection are mediated by the
effect of exotoxin (tetanospasmin) on the central nervoUs system. This toxin is distributed
through out the body in the blood stream and is taken by peripheral endings of motor neurons,
sensory and autonomic fibres. 18 The toxin reaches the oentral nervous system by intra axonal
retrograde transport. 1 9 Tetanospasmin is postulated to cause disinhibition of the sympathetic
nervous system. 1

Case Report
A 29 year old female, with no history of tetanus immunisation, was admitted to a medical ward
for management of tetanus. She had a one week history of low grade fever with chill and rigors
and a two day history of neck pain and trismus. She was a widow with two children and her last
menopausal period (LMP) was two weeks prior to admission. Previous medical history was
insignificant.

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On admission she was conscious and rational but febrile 38°C. She had mild trismus and stiffnes~
in the back. No obvious recent external injuries or wounds were noted. Her vital signs were stable',
A clinical diagnosis of tetanus was made. Antitetanus toxoi~ (ATT) 1 ampule (0.5 ml) and Tetanus
Immunoglobulin Human (TIG) 5000 units were given intra'muscularly; and chlorpromazine 50mg
6 hourly by intravenous injection was commenced. An intravenous infusion of diazepam
started at'a rate of 4 mg per hour resulted in considerable reduction in her muscle tone. She was
nursed in a dark room and did well for three days. On the fourth day of admission, she
developed respiratory distress and dysphagia. She also had increasing generalised muscle spasms.
The arterial blood gases showed acute respiratory failure. The patient was then referred to an
intensive care unit (lCD) for elective ventilation. In ICD, the patient was paralysed with
d-tubocurarine 30mg LV. and nasotracheal intubation was performed using a 7.5mm nasotracheal
tube without difficulty. Controlled ventilation was indicated in this case and muscle relaxation
was provided by top up doses of d-tubocurarine. She was put on crystalline penicillin 2 mega
unit LV. 6-hourly, gentamicin 60mg LV. 8:hourly and metronidazole 500mg LV. 8-hourly. Good
control of spasms and sedation were achieved with diazepam infusion at rate of lOmg per hour.
The patient remained febrile (low grade) until the third day of ICU admission, whp.n her
temperature went up to 39°C and foul smelling discharge was noted by the intensive care nurse.
The source of discharge was found to be from the vagina. The patient was subsequently referred
to the obstetrician and gynaecologist for further examination. A diagnostic dilatation and
curretage (DD & C) was performed under general anaesthesia. The findings were: uterus 12 week
size with tubular cervix and opened os. On cunetting there were multiple sharp and small bamboo
sticks (1 to 2 cm in length) tied together with threads, presumably broken during induced
abortion. Our impression was tetanus following septic abortion. The patient had persistent fever
and a repeat DD & C was performed. The antibiotics were changed to cefoperazone 1 gm LV.
l2-hourly and metronidazole 500 mg LV. 6-hourly. She remained febrile for one week. During this
time she developed upper lobe collapse - consolidation and pleural effusion. Her vital signs
remained stable. Tracheal aspirate revealed methicilin resistant Staph aureus and only sensitive to
rifampicin and fucidic acid. Subsequently she received these two new antibiotics. The temperature
started settling down the next day. She was in leD for five weeks and was finally discharged well.

Discussion
Clostridium tetani is not an invasive organism. The infection remains localised in an area of low
oxygen-reduction potential into which spores have been introduced. 3 The presence of low oxygen,
necrotic tissue and foreign bodies favour the organism to multiply. 3 The diagnosis of tetanus is
usually made from clinical signs rather than laboratory investigations and the best management
is a team approach in the intensive care unit. Tetanus after induced abortion begins with the
use of unclean instruments. In this patient, bamboo sticks were used to induce abortion by
traditional means. Multiplication of the organism is facilitated by the presence of devitalised
tissue, blood clots and threads,

After an incubation' period ranging from one to 54 days 3 (in this case the incubation period
was probably nine days), the toxin will cause full ·blown clinical tetanus in nonimmunised
patients. This pathophysiological sequence should remind doctors of two important levels to
consider. Doctors should determine the immunisation status of every patient and secure in those
with unknown or incomplete history, adequate tetanus prophylaxis prior to elective or
emergency syrgery. Furthermore a.septic technique should be-achieved at all times of surgery,
as well as to remove any foreign bodies and blood clots. All these will prevent the development
of areas of low oxygen reduction potential. The diagnosis of tetanus in this case was straight

350
forward but the SOurce of infection was unknown until the patient developed foul smelling
discharge from the vagina. The problem here was that incorrect information given by the patient
resulting in the delay to locate and eradicate the source of infection. This patient developed
bronchopulmonary infection and the organism responsible was Staph aureus. She also had pleural
effusion, However complications that occurred during the course of the disease were sometimes
difficult to overcome and probably related to the duration of stay in ICU. Their incidence could
be reduced by more meticulous patient care. 4 Fortunately this patient did not suffer from the
syndrome of sympathetic nervous hyperactivity, brainstem lesions or toxic myocarditis.} ,6,20
Sympathetic nervous system disturbances in severe tetanus have been confirmed by several
workers and various agents have been used to control this potentially life threatening
complication. Brainstem lesions can cause sudden apnoea or sudden cardiac arrest. In some
patients who have died suddenly, a patchy myocardial necrosis without inflammatory infIltrate
has been found at post mortem. 20 This toxic myocarditis was thought to be due to a direct action
of a tetanospasmin. little has been written regarding parasympathetic nervous system involvement
in tetanus. 20 However in severe tetanus sympathetic inhibition is defective thereby allowing
intensive overriding vagal excitation to occur. 1 Or the effects of tetanus toxin on the
parasympathetic nervous system have been overlooked even though preterminal bradycardia and
sinus arrest, salivation and increased br.onchial secretions are frequently observed in severe cases. 1

lllegal induced abortion was most likely in this case as the DD & C revealed multiple bamboo
sticks tied together with threads. illegal induced abortion is a common cause of death among
women particularly in many developing countries of the. world. 2 1 However the number of reports
on illegally induced abortion mortality is relatively small. 2 2 In countries where there is no
liberal abortion law there is always a desperate effort at risk to the life. and health of the
woman to terminate an unwanted pregnancy illegally. This report should alert doctors. that female
patients who develop tetanus with an unclear source of infection, may have undergone an illegai
induc.ed abortion.

Acknowledgement
I thank Cik Ena @ Aminah bte Othman f~r typing the manuscript.

351
References
1. Wright DK, LaIlo VG, Nayiagers, Govender P. 12. Clay RC, Bolton JW. Tetanus arising from
Autonomic nervous system dysfunction in gangrenous small intestine. JAMA 1964;
severe tetanus: current perspective. Crit Care 187: 856-858
Med 1989; 17: 371-375
13. Segel J, Shaff BL. An unusual case of post-
2. Bowen V, Johnson J, Boyle J, Snelling CFT. operative tetanus. Afr Med J 1969; 43:
Tetanus - a continuing problem in minor 1556-1557
injuries. Can J Surg 1988; 31: 7-9
14. Murphy KJ, Heppell T, Bode WE. Tetanus
3. Fleshner PR, Hunter JG, Rudick J. Tetanus after rubber band ligation of hemorrhoids.
after gastrointestinal surgery. The Am J Br Med J 1978; 1: 1590-1591
Gastroenterol1988; 83: 298-300.
15. Croekert F, Glupczynski Y, Fastrez R. Post-
4. Udwadia FE, LaIl A, Vdwadia ZF, Sekhar M. operative tetanus Lancet 1984; 1: 1466
Tetanus' and its complications: intensive care
management experience in 150 patients. 16. Myers KJ, Heppell T, Bode WE. T~tanus after
Epidemiology and Infection 1987; 99: 675- anorectal abscess. Mayo Clin Proc 1984; 59;
684. 429-430

5. Trujillo MH, Castillo A, Espana J, Manzo A, 17. Wright G. Neurotoxins of Clostridium botuli-
Zerpa R Impact of intensive care manage- num and Clostridium tetani. Pharmacol Rev
ment on the prognosis of tetanus. Analysis of 1955; 7: 413-422
641 cases. Chest 1987; 92: 63-65
18. Bevan S Weondon LMB. A study of the action
6. Tsueda K, Oliver PB, Richter RW. Cardio- of tetanus toxin at rat soleus neuromuscular
vascular manifestations of tetanus. Anaesthe- junctions. J Physiol1984; 348:1
.siology 1974; 40: 588-592
19. Erdman G, Weigard H, Wellhoner HH. Intra-
7. Acres SE. Statement on tetanus toxoid. Can axonal and extraxonal transport of 125 1-
Med Assoc J 1987; 137: 734 tetanus toxin in early local tetanus. Naunyn
Schmiedebergs Arch Pharmacol 1975; 290:
8. Public Health Laboratory Service Communi- 237
cable Disease Surveillance Centre. Communi-
cable Diseases; Tetanus surveillance: England 20. Hollow VM, Clarke GM. Autonomic manifes-
and Wales, 1981-3. Br Med J 1985; .290: tations of tetanus. Anaesth Intensive Care
696-697 1975; 3: 142-147

9. Aubert JM, Olle-Goig JE. Tetanus complica- 21. Adetoro 00. A· 15-year study of illegally
ting elective surgery: Two cases following induced abortion mortality at Illorin, Nigeria.
female sterilization. Trop Doct 1983; 13: 61- Int J Gynecol Obstet 1989; 29: 65-72
64.
22. Bognar Z, Czeizel A. Mortality and Morbidity
10. Cone LA, Fenester FS. Tetanus "following associated with Legal abortion in Hungary
a dental operation. Ciilifomia Medicine 1973; 1960-1973. Am J Public Health 1979; 66
119: 57-58 (6): 568
p. Bunch GH, Quattlebaum J. Postoperative 23. Rice-Wray E. The provoked abortion - a
tetanus. Am J Surg 1943; 61: 280-285 major public health problem. Am J Public
Health 1964; 54(2): 313

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