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Tuboovarian abscess associated with laparoscopic tubal cauterization and the intrauterine contraceptive device
Volume Number
119 8
Communications
occasionally
for
benign
In view of the lar metabolism, cause-and-effect the medication
diseases,
such
as psoriasis.
ability of this drug to alter celluthere appears to be an interesting relationship between the use of and the appearance of carcinoma
in situ
in the
cervix.
The Danyluk cordia
assistance of Drs. Don Young and John of the Department of Pathology, MiseriHospital, is gratefully acknowledged.
Tu boovarian abscess associated with laparoscopic tubal cauterization and the intrauterine contraceptive device FRANK
C.
WRIGHT,
M.D.,
F.A.C.O.G. Department Rirjerside BOTH
of Obstetrics and Gynecology, Methodist Hospital, Columbus,
INTRAUTERINE
DEVICE
utilization and laparoscopic have become commonplace
Ohio (IUD)
tuba1 cauterization in current medical
practice. Because of this trend, IUD removal directly followed by laparoscopic tuba1 cauterization could be occurring with increasing frequency. Recently, three cases of pelvic abscess unrelated to bowel injury complication of The suggested infection is a tritis resulting is exacerbated subsequent
were reported as a postoperative laparoscopic tubal cauterization.’ etiology of this type of pelvic chronic low-grade focal endomefrom the IUD. This endometritis
by the curettage
parametrial area tubal cauterization.
by
removal of the and propagated
IUD in
and the
tissue damage secondary Recognizing the difficulty
to in
drabving conclusions from small numbers of cases, I wish to add the following case to the literature. This case seems to reaffirtn the suspicion that tubal cauterization preceded by IUD removal and subsequent curettage can lead to adnexitis and pelvic abscess. J. P.? a 35-year-old, white woman, para 4-O-O-4, was admitted through the emergency room on February 6 with the acute onset of right adnexal pain. She had been eumenorrheic prior to admission, and an IUD had been in place for 5 years. The last normal menstrual period started on February 1, 1973, 5 days prior to admission. The menstrual flow was just terminating when she was Reprirlt requests: Dr. Frank Worthin,qton, Ohio 43085.
C. Wright,
6660 N. High St.,
in brief
1133
admitted. She gave a past history of moderate dysmenorrhea since the insertion of the IUD; however, on the day of admission, she was awakened in the morning by severe right adnexal pain without radiation. She had no associated gastrointestinal or urinary tract symptoms. Several months prior to admission, she did note the gradual onset of rightsided bumper dyspareunia. When seen in the emergency room, vital signs and laboratory work, including complete blood count, sedimentation rate, urinary chorionic gonadotropins, and urinalysis, were within normal limits. The abdomen was soft; there was no guarding or rebound, and bowel sounds were normal. She had no shoulder pain. The cervix appeared to be normal. The terminal filament of the IUD was present at the external cervical OS. The uterus was anterior, freely movable, and nontender. There was a 4 to 5 cm. cystic mass in the right posterior cul-de-sac. The left adnexal structures were unremarkable. Because of the progressively increasing menorrhagia and dysmenorrhea, the patient requested that the IUD be removed. This was carried out in the emergency room without difficulty, and the patient was admitted for observation with a diagnosis of an adnexal accident, probably involving a functional right ovarian cyst. Shortly after admission the patient’s pain improved, and 24 hours after admission repeat pelvic examination revealed no pelvic mass. Since the patient was interested in a sterilization procedure, she was subjected to examination under anesthesia, curettage, and laparoscopy for both the determination of the etiology of the adnexal pain and the tuba1 cauterization, despite the fact that the pelvic pain was improved. At the time of laparoscopy, the right ovary appeared to have a ruptured cyst in its distal pole. There was 10 to 15 C.C. of serosanguineous fluid in the cul-de-sac. Uneventful bilateral tuba1 cauterization and division were carried out. Histologic examination of the curettings revealed proliferative endometrium with focal glandular hyperplasia and dilated glands which contained polymorphonuclear leukocytic exudate. The stroma contained several coiled arterioles and an infiltrate with lymphocytes, but no plasma cell infiltrate was seen. The patient was discharged on the first postoperative day with the diagnosis of a ruptured functional right ovarian cyst. She was readmitted on February 25, 17 days after laparoscopy, with right adnexal pain and fever. These symptoms had developed 3 days prior to admission and had been increasing in severity. She was admitted with a temperature of 100” F. and a pulse of 90. The sedimentation rate was corrected to 36 mm. per hour. The hemoglobin was 12.5, the hematocrit was 37, and the white blood cell count was 17,700. The urinalysis was normal. There were severe pain and guarding in the right lower quadrant. Bowel sounds were active, with no associated nausea and vomiting. On pelvic examination, there was an extremely tender 6 to 7 cm. right adnexal mass fixed to the uterus and the right pelvic side wall. The patient
1134
Communications
hqust
in brief
Am. .J. Ohstet.
was given fluids and intravrnous gentamicin sulfate* and clindamyrin hydrochloride.+ After 24 hours with no improvement, examination with anesthesia and pelvic laparotomy revealed an 8 cm. right tuboovarian abscess with the terminal 1 cm. of the appendix involved in the abcess formation. Cultures at the time of operation revealed no growth. Pathologic examination revealed the appendix to he normal with the exception of periappendicitis which would suggest the etiology of the abscess to be other than the gastrointestinal tract. Total abdominal hysterectomy, bilateral salpingo-oophorertomy, and appendectomy were “Garamycin,
Schering
tClewin, Thr ,Michiyan 43001.
Upjohn
Corp.,
1011
Mot I is A\e.:
c,arried pelvis, gutter,
my
15, 19i-l Gynecol.
ou!. Hemavac drains were placed in the and Penrose drains were placed in the right flank, and subfascial areas.
lifter experience policy to remove
with this case, it has been IUD’s one menstrual inter-
val prior tcr anticipated laparoscopic tubal cauterization. When this is not possible, the patient is ,given prophylactic antibiotics during thr procedure and in the immediate postoperative period.
Union. REFERENCE
Attention
Co..
7171 l’ort:~~~:
to authors:
Rd.,
Section
Kalamazoo,
on
Clinical
I.
Badra, Gynrcol.
P. I,.. IYoung, J. 42: ,511, 1973.
R.,
et
al::
Opinion
The editors and publisher of the AMERICAN JOURNAL OF OBSTETRICS APU‘D GYNECOLOC\ wish to call your attention to a new section entitled “Clinical Opinion.” The section will be devoted to the clinical diagnosis and management of certain disease entities. The section is designed to accommodate from eight to twenty typed pages with appropriate illustrative material, tables, and figures helpful in clarifying to the reader how a condition is actually managed. References need not be extensive, since the emphasis should be on the author’s actual handling of clinical problems. The objective of this section is to transmit to the reader how a clinical situation is actually handled. Manuscripts should be submitted to Frederick P. Zuspan, M.D., Editor, American Journal of Obstetrics and Gynecology, 5841 3. Maryland Ave., Chicago, Illinois 60637.
Obstct.
119 8
Communications
occasionally
for
benign
In view of the lar metabolism, cause-and-effect the medication
diseases,
such
as psoriasis.
ability of this drug to alter celluthere appears to be an interesting relationship between the use of and the appearance of carcinoma
in situ
in the
cervix.
The Danyluk cordia
assistance of Drs. Don Young and John of the Department of Pathology, MiseriHospital, is gratefully acknowledged.
Tu boovarian abscess associated with laparoscopic tubal cauterization and the intrauterine contraceptive device FRANK
C.
WRIGHT,
M.D.,
F.A.C.O.G. Department Rirjerside BOTH
of Obstetrics and Gynecology, Methodist Hospital, Columbus,
INTRAUTERINE
DEVICE
utilization and laparoscopic have become commonplace
Ohio (IUD)
tuba1 cauterization in current medical
practice. Because of this trend, IUD removal directly followed by laparoscopic tuba1 cauterization could be occurring with increasing frequency. Recently, three cases of pelvic abscess unrelated to bowel injury complication of The suggested infection is a tritis resulting is exacerbated subsequent
were reported as a postoperative laparoscopic tubal cauterization.’ etiology of this type of pelvic chronic low-grade focal endomefrom the IUD. This endometritis
by the curettage
parametrial area tubal cauterization.
by
removal of the and propagated
IUD in
and the
tissue damage secondary Recognizing the difficulty
to in
drabving conclusions from small numbers of cases, I wish to add the following case to the literature. This case seems to reaffirtn the suspicion that tubal cauterization preceded by IUD removal and subsequent curettage can lead to adnexitis and pelvic abscess. J. P.? a 35-year-old, white woman, para 4-O-O-4, was admitted through the emergency room on February 6 with the acute onset of right adnexal pain. She had been eumenorrheic prior to admission, and an IUD had been in place for 5 years. The last normal menstrual period started on February 1, 1973, 5 days prior to admission. The menstrual flow was just terminating when she was Reprirlt requests: Dr. Frank Worthin,qton, Ohio 43085.
C. Wright,
6660 N. High St.,
in brief
1133
admitted. She gave a past history of moderate dysmenorrhea since the insertion of the IUD; however, on the day of admission, she was awakened in the morning by severe right adnexal pain without radiation. She had no associated gastrointestinal or urinary tract symptoms. Several months prior to admission, she did note the gradual onset of rightsided bumper dyspareunia. When seen in the emergency room, vital signs and laboratory work, including complete blood count, sedimentation rate, urinary chorionic gonadotropins, and urinalysis, were within normal limits. The abdomen was soft; there was no guarding or rebound, and bowel sounds were normal. She had no shoulder pain. The cervix appeared to be normal. The terminal filament of the IUD was present at the external cervical OS. The uterus was anterior, freely movable, and nontender. There was a 4 to 5 cm. cystic mass in the right posterior cul-de-sac. The left adnexal structures were unremarkable. Because of the progressively increasing menorrhagia and dysmenorrhea, the patient requested that the IUD be removed. This was carried out in the emergency room without difficulty, and the patient was admitted for observation with a diagnosis of an adnexal accident, probably involving a functional right ovarian cyst. Shortly after admission the patient’s pain improved, and 24 hours after admission repeat pelvic examination revealed no pelvic mass. Since the patient was interested in a sterilization procedure, she was subjected to examination under anesthesia, curettage, and laparoscopy for both the determination of the etiology of the adnexal pain and the tuba1 cauterization, despite the fact that the pelvic pain was improved. At the time of laparoscopy, the right ovary appeared to have a ruptured cyst in its distal pole. There was 10 to 15 C.C. of serosanguineous fluid in the cul-de-sac. Uneventful bilateral tuba1 cauterization and division were carried out. Histologic examination of the curettings revealed proliferative endometrium with focal glandular hyperplasia and dilated glands which contained polymorphonuclear leukocytic exudate. The stroma contained several coiled arterioles and an infiltrate with lymphocytes, but no plasma cell infiltrate was seen. The patient was discharged on the first postoperative day with the diagnosis of a ruptured functional right ovarian cyst. She was readmitted on February 25, 17 days after laparoscopy, with right adnexal pain and fever. These symptoms had developed 3 days prior to admission and had been increasing in severity. She was admitted with a temperature of 100” F. and a pulse of 90. The sedimentation rate was corrected to 36 mm. per hour. The hemoglobin was 12.5, the hematocrit was 37, and the white blood cell count was 17,700. The urinalysis was normal. There were severe pain and guarding in the right lower quadrant. Bowel sounds were active, with no associated nausea and vomiting. On pelvic examination, there was an extremely tender 6 to 7 cm. right adnexal mass fixed to the uterus and the right pelvic side wall. The patient
1134
Communications
hqust
in brief
Am. .J. Ohstet.
was given fluids and intravrnous gentamicin sulfate* and clindamyrin hydrochloride.+ After 24 hours with no improvement, examination with anesthesia and pelvic laparotomy revealed an 8 cm. right tuboovarian abscess with the terminal 1 cm. of the appendix involved in the abcess formation. Cultures at the time of operation revealed no growth. Pathologic examination revealed the appendix to he normal with the exception of periappendicitis which would suggest the etiology of the abscess to be other than the gastrointestinal tract. Total abdominal hysterectomy, bilateral salpingo-oophorertomy, and appendectomy were “Garamycin,
Schering
tClewin, Thr ,Michiyan 43001.
Upjohn
Corp.,
1011
Mot I is A\e.:
c,arried pelvis, gutter,
my
15, 19i-l Gynecol.
ou!. Hemavac drains were placed in the and Penrose drains were placed in the right flank, and subfascial areas.
lifter experience policy to remove
with this case, it has been IUD’s one menstrual inter-
val prior tcr anticipated laparoscopic tubal cauterization. When this is not possible, the patient is ,given prophylactic antibiotics during thr procedure and in the immediate postoperative period.
Union. REFERENCE
Attention
Co..
7171 l’ort:~~~:
to authors:
Rd.,
Section
Kalamazoo,
on
Clinical
I.
Badra, Gynrcol.
P. I,.. IYoung, J. 42: ,511, 1973.
R.,
et
al::
Opinion
The editors and publisher of the AMERICAN JOURNAL OF OBSTETRICS APU‘D GYNECOLOC\ wish to call your attention to a new section entitled “Clinical Opinion.” The section will be devoted to the clinical diagnosis and management of certain disease entities. The section is designed to accommodate from eight to twenty typed pages with appropriate illustrative material, tables, and figures helpful in clarifying to the reader how a condition is actually managed. References need not be extensive, since the emphasis should be on the author’s actual handling of clinical problems. The objective of this section is to transmit to the reader how a clinical situation is actually handled. Manuscripts should be submitted to Frederick P. Zuspan, M.D., Editor, American Journal of Obstetrics and Gynecology, 5841 3. Maryland Ave., Chicago, Illinois 60637.
Obstct.