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.