Case 1
N.A., a 31-year old female, para 2, abortus 1, at 5 weeks of amenorrhea
and HIV negative, was admitted to our Gynecology ward via the Emergency
Department. The patient presented with a 2-week history of lower
abdominal pain, 3 days of vomiting, and 2 days of loose stools. She did
not report any bleeding or discharge per vagina; the micturition habit
was normal. She reported not being pregnant in recent months and that
the symptoms started spontaneously, without any identifiable cause, and
worsened progressively.
At admission, the patient was conscious, with Glasgow Coma Scale (GCS)
of 15/15, but pale and in obvious discomfort; her blood pressure (BP)
was 96/56 mmHg, pulse rate (PR) was 112 beats per minute and temperature
was 38.7°C. Abdominal examination revealed severe distension,
generalized tenderness, and guarding; bowel sounds were present. The
vaginal examination demonstrated no active bleeding but moderate
foul-smelling discharge; the cervical os was closed. At the bimanual
examination, the uterus was bulky, with severe cervical motion
tenderness. The physical examination of the other systems was
unremarkable.
Her blood investigations showed hemoglobin (Hb) of 6.5 gm/dl, white cell
count of 32.3×109/l, platelets of
105×109/l. The urine human chorionic gonadotropin
(hCG) quick test was positive. A pelvic ultrasound (US) scan showed an
empty and bulky uterus, normal-looking ovaries, and the presence of an
echogenic pelvic mass; a diagnosis of a pelvic abscess was made and an
exploratory laparotomy planned, after resuscitation of the patient.
During the exploratory laparotomy, the uterus was severely necrotic and
there was pus collection of 2 litres in the paracolic gutters and the
sub-diaphragmatic recess.
During the postoperative period, antibiotic therapy with intravenous
first line broad-spectrum antibiotics was performed, but the patient
remained febrile and started discharging pus from the laparotomy wound
on the 5th postoperative day. A wound swab culture was
performed, revealing a multi-resistant Escherichia coli ,
sensitive to Gentamicin and Chloramphenicol. Therapy with a combination
of these antibiotics did not show any improvement in the following days
and, on the 15thpostoperative day, the incision site
started gaping, with copious pus discharge.
A further pelvic ultrasound scan showed an echo-complex fluid collection
in the pouch of Douglas, with a volume of around 265ml; the findings
were in line with a pelvic abscess. A repeat laparotomy confirmed the
diagnostic hypothesis and an extensive pelvic lavage was done. The
patient was treated postoperatively with a reserve antibiotic
(intravenous Meropenem) and after 10 days was discharged home in good
general conditions, on oral antibiotics. At discharge from the hospital,
the patient reported having induced the abortion with a local herb,
known as “wandering jew”, three weeks before admission, by inserting
some pieces of the stem of the plant in the vagina; a few days after the
expulsion of the fetus, she started developing lower abdominal pain and
abdominal distension, associated with per vagina foul-smelling
discharge.