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Pelvic Abscess Caused by Fusobacterium nucleatum: A Case Report and Review of Literature
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Abstracts / Journal of Minimally Invasive Gynecology 18 (2011) S116–S131
Design: Case report. Setting: University teaching hospital in London. Patients: A 21 year old in her second pregnancy presented with acute abdominal pain at 14 weeks gestation. On scan, a 84x 57x 68 mm cystic mass was present in the lower abdomen. Inflammatory and tumour markers were normal. As symptoms resolved with conservative management, a decision was made not to proceed with surgery. She was readmitted with a further episode of severe pain at 18 weeks. At scan, the cyst had enlarged to over 10 cm. As symptoms were persistent, laparoscopic cystectomy was perform. Intervention: Open laparoscopy was performed through Palmer’s point maintaining low pressure pneumoperitoneum. The ovarian cyst had twisted twice round its pedicle. The ovary was detorted laparoscopy. To minimise risk to the ongoing pregnancy from chemical peritonitis, controlled drainage was performed. An Alexis retractor was introduced though a lateral port, cyst decompressed with no spillage and cystectomy performed. She made an excellent recovery and was discharged home the next day. Measurements and Main Results: Histology showed an unilocular cyst with a mixed epithelial lining. The stroma contained mature hyaline cartilage, adnexal structures and salivary gland tissue. Well formed prostatic glands and surrounding fibromuscular stroma was present. The prostatic glands were weakly positive for both PSA and PSAP. Conclusion: Prostatic tissue in a 46xx tumour suggests induction by locally produced androgen. Some investigatiors have identified lutenised stromal cells, ovarian hilar cells, adrenal cortex as the source of androgen. In this case, the hormonal changes of pregnancy may have been a contributory factor.
POSTER SESSION: EDUCATION 401 Pelvic Abscess Caused by Fusobacterium nucleatum: A Case Report and Review of Literature Aslih N,1 Anderman S,1 Groisman G,2 Hallak M.1 1Obstetrics and Gynecology, Hillel Yaffe Medical Center, Hadera, Israel, Israel; 2 Department of Pathology, Hillel Yaffe Medical Center, Hadera, Israel, Israel Study Objective: Fusobacterium species are Gram negative anaerobic rods that are part of the normal flora of mucosal surfaces. They are found in large numbers in the oral cavity but are not a major part of the vaginal flora. An unusual case of pelvic abscess caused by fusobacterium is reported. An eighteen-year-old nullipara presented to the emergency ward with low abdominal pain. Ten weeks earlier she underwent a curettage for incomplete abortion and since then she was amenorrheic. B-hcg test was negative. The gynecological examination revealed a solid, non tender mass located to the left of the pelvis. Transvaginal sonography demonstrated a normal sized uterus being pushed to the anterior pelvic wall by a huge left adnexal mass of 12 cm of diameter. Histopathologic report of the curettings 10 weeks earlier revealed: ‘‘necrotic placental tissue filled with clones of actinomycosis’’. On the 2nd day of her hospitalization she developed fever, leukocytosis and raise in creatinine levels. CT scan of the abdomen showed a huge pelvic mass, apparently originating in the left adnexa, causing dilatation of the the left ureter. Laparoscopy revealed a ruptured, huge pelvic abscess originating in the left adnexa with large amount of pus in the abdominal cavity. Conversion to laparotomy was performed. After extensive adhesiolysis left salpingooophorectomy was performed. The uterus and right adnexa were unaffected. The cultures of the peritoneal fluid showed: Fusobacterium nucleatum. A revision of the first histopathologic report was done and corrected to: ‘‘few placental villi and hemorrhagic decidua filled with areas of necrosis and clones of Fusobacterium nucleatum’’. This case presents a very rare and unusual presentation of Fusobacterium infection. The most logical explanation of the fact that a minor unimportant microorganism (which is considered a part of normal flora) caused such
a suppurative infection is a possible uterine wall perforation during the curettage the woman had underwent.
402 A National Survey of Endoscopic Practice among ObstetricianGynaecologists in Canada Chen I,1 Bajzak KI,2 Guo Y,3 Singh SS.3 1Obstetrics and Gynecology, University of Alberta, Edmonton, Alberta, Canada; 2Obstetrics and Gynecology, Memorial University, St John’s, Newfoundland, Canada; 3 Obstetrics and Gynecology, University of Ottawa, Ottawa, Ontario, Canada Study Objective: To assess the current status of endoscopic gynaecological surgery in Canada, as well as the attitudes, perceptions, and educational preferences regarding endoscopy among Canadian obstetriciangynaecologists. Design: A national electronic on-line survey study. Setting: Canada. Patients: 630 obstetrician-gynaecologists in Canada identified using the Society of Obstetrics and Gynaecology electronic mailing list. Intervention: Survey participants were asked about demographic variables, level of training and current practice of endoscopic procedures, reasons and barriers to performing endoscopy, and interest in continuing medical education on endoscopy. Measurements and Main Results: A total of 177 (28%) completed responses were tallied. The majority of respondents were general obstetrician-gynaecologists (75%) with a high rate of subspecialty interest in minimally invasive gynaecology. More gynaecologic surgeons performed abdominal (93%) and vaginal hysterectomies (90%) than laparoscopic assisted vaginal hysterectomies (62%), laparoscopic supracervical hysterectomies (29%), total laparoscopic hysterectomies (43%), and robotic hysterectomies (3%). Even though 92% of respondents selected the endoscopic approach as the preferred approach to surgery for their patients, 46% of English responders and 8% of French responders did not feel that they were trained adequately during residency to perform endoscopy. Lack of OR resources and lack of time and opportunity for further training were frequently selected as major barriers to performing endoscopy. Trained endoscopic surgeon outreach was identified as a preferred method of acquiring endoscopic skills. Conclusion: This survey provides a contemporary assessment of the current endoscopic practice patterns of Canadian obstetrician-gynaecologists and helps to identify some potentially modifiable factors hindering the practice of endoscopy and some possible solutions to overcoming these barriers. 403 Hysteroscopic Transection of Uterine Septum Daw MA, Miller CE. Obstetrics and Gynecology, Advocate Lutheran General Hospital, Park Ridge, Illinois Study Objective: The septate uterus is the most common mullerian anomaly with the poorest associated reproductive outcomes. These outcomes include recurrent pregnancy loss, preterm labor, malpresentation, and infertility. The simplicity of hysteroscopic septoplasty, with its’ low complication rates and postoperative sequelae, provides remarkable improvements in reproductive performance. There is a movement currently to liberalize the use of hysteroscopic transection of uterine septum from only those patients with a history of recurrent miscarriage to include those with unexplained primary infertility. In this role, septoplasty provides a prophylactic strategy against poor obstetric outcomes but also potentially functions as a therapeutic maneuver. In women with longstanding infertility and with waning fecundity (>35 yr) who are planning ART this is particularly compelling. This chapter describes in detail the definition and prevalence of the septate uterus. It includes the affect on fertility and gestational performance, diagnostic strategies,
Abstracts / Journal of Minimally Invasive Gynecology 18 (2011) S116–S131
Design: Case report. Setting: University teaching hospital in London. Patients: A 21 year old in her second pregnancy presented with acute abdominal pain at 14 weeks gestation. On scan, a 84x 57x 68 mm cystic mass was present in the lower abdomen. Inflammatory and tumour markers were normal. As symptoms resolved with conservative management, a decision was made not to proceed with surgery. She was readmitted with a further episode of severe pain at 18 weeks. At scan, the cyst had enlarged to over 10 cm. As symptoms were persistent, laparoscopic cystectomy was perform. Intervention: Open laparoscopy was performed through Palmer’s point maintaining low pressure pneumoperitoneum. The ovarian cyst had twisted twice round its pedicle. The ovary was detorted laparoscopy. To minimise risk to the ongoing pregnancy from chemical peritonitis, controlled drainage was performed. An Alexis retractor was introduced though a lateral port, cyst decompressed with no spillage and cystectomy performed. She made an excellent recovery and was discharged home the next day. Measurements and Main Results: Histology showed an unilocular cyst with a mixed epithelial lining. The stroma contained mature hyaline cartilage, adnexal structures and salivary gland tissue. Well formed prostatic glands and surrounding fibromuscular stroma was present. The prostatic glands were weakly positive for both PSA and PSAP. Conclusion: Prostatic tissue in a 46xx tumour suggests induction by locally produced androgen. Some investigatiors have identified lutenised stromal cells, ovarian hilar cells, adrenal cortex as the source of androgen. In this case, the hormonal changes of pregnancy may have been a contributory factor.
POSTER SESSION: EDUCATION 401 Pelvic Abscess Caused by Fusobacterium nucleatum: A Case Report and Review of Literature Aslih N,1 Anderman S,1 Groisman G,2 Hallak M.1 1Obstetrics and Gynecology, Hillel Yaffe Medical Center, Hadera, Israel, Israel; 2 Department of Pathology, Hillel Yaffe Medical Center, Hadera, Israel, Israel Study Objective: Fusobacterium species are Gram negative anaerobic rods that are part of the normal flora of mucosal surfaces. They are found in large numbers in the oral cavity but are not a major part of the vaginal flora. An unusual case of pelvic abscess caused by fusobacterium is reported. An eighteen-year-old nullipara presented to the emergency ward with low abdominal pain. Ten weeks earlier she underwent a curettage for incomplete abortion and since then she was amenorrheic. B-hcg test was negative. The gynecological examination revealed a solid, non tender mass located to the left of the pelvis. Transvaginal sonography demonstrated a normal sized uterus being pushed to the anterior pelvic wall by a huge left adnexal mass of 12 cm of diameter. Histopathologic report of the curettings 10 weeks earlier revealed: ‘‘necrotic placental tissue filled with clones of actinomycosis’’. On the 2nd day of her hospitalization she developed fever, leukocytosis and raise in creatinine levels. CT scan of the abdomen showed a huge pelvic mass, apparently originating in the left adnexa, causing dilatation of the the left ureter. Laparoscopy revealed a ruptured, huge pelvic abscess originating in the left adnexa with large amount of pus in the abdominal cavity. Conversion to laparotomy was performed. After extensive adhesiolysis left salpingooophorectomy was performed. The uterus and right adnexa were unaffected. The cultures of the peritoneal fluid showed: Fusobacterium nucleatum. A revision of the first histopathologic report was done and corrected to: ‘‘few placental villi and hemorrhagic decidua filled with areas of necrosis and clones of Fusobacterium nucleatum’’. This case presents a very rare and unusual presentation of Fusobacterium infection. The most logical explanation of the fact that a minor unimportant microorganism (which is considered a part of normal flora) caused such
a suppurative infection is a possible uterine wall perforation during the curettage the woman had underwent.
402 A National Survey of Endoscopic Practice among ObstetricianGynaecologists in Canada Chen I,1 Bajzak KI,2 Guo Y,3 Singh SS.3 1Obstetrics and Gynecology, University of Alberta, Edmonton, Alberta, Canada; 2Obstetrics and Gynecology, Memorial University, St John’s, Newfoundland, Canada; 3 Obstetrics and Gynecology, University of Ottawa, Ottawa, Ontario, Canada Study Objective: To assess the current status of endoscopic gynaecological surgery in Canada, as well as the attitudes, perceptions, and educational preferences regarding endoscopy among Canadian obstetriciangynaecologists. Design: A national electronic on-line survey study. Setting: Canada. Patients: 630 obstetrician-gynaecologists in Canada identified using the Society of Obstetrics and Gynaecology electronic mailing list. Intervention: Survey participants were asked about demographic variables, level of training and current practice of endoscopic procedures, reasons and barriers to performing endoscopy, and interest in continuing medical education on endoscopy. Measurements and Main Results: A total of 177 (28%) completed responses were tallied. The majority of respondents were general obstetrician-gynaecologists (75%) with a high rate of subspecialty interest in minimally invasive gynaecology. More gynaecologic surgeons performed abdominal (93%) and vaginal hysterectomies (90%) than laparoscopic assisted vaginal hysterectomies (62%), laparoscopic supracervical hysterectomies (29%), total laparoscopic hysterectomies (43%), and robotic hysterectomies (3%). Even though 92% of respondents selected the endoscopic approach as the preferred approach to surgery for their patients, 46% of English responders and 8% of French responders did not feel that they were trained adequately during residency to perform endoscopy. Lack of OR resources and lack of time and opportunity for further training were frequently selected as major barriers to performing endoscopy. Trained endoscopic surgeon outreach was identified as a preferred method of acquiring endoscopic skills. Conclusion: This survey provides a contemporary assessment of the current endoscopic practice patterns of Canadian obstetrician-gynaecologists and helps to identify some potentially modifiable factors hindering the practice of endoscopy and some possible solutions to overcoming these barriers. 403 Hysteroscopic Transection of Uterine Septum Daw MA, Miller CE. Obstetrics and Gynecology, Advocate Lutheran General Hospital, Park Ridge, Illinois Study Objective: The septate uterus is the most common mullerian anomaly with the poorest associated reproductive outcomes. These outcomes include recurrent pregnancy loss, preterm labor, malpresentation, and infertility. The simplicity of hysteroscopic septoplasty, with its’ low complication rates and postoperative sequelae, provides remarkable improvements in reproductive performance. There is a movement currently to liberalize the use of hysteroscopic transection of uterine septum from only those patients with a history of recurrent miscarriage to include those with unexplained primary infertility. In this role, septoplasty provides a prophylactic strategy against poor obstetric outcomes but also potentially functions as a therapeutic maneuver. In women with longstanding infertility and with waning fecundity (>35 yr) who are planning ART this is particularly compelling. This chapter describes in detail the definition and prevalence of the septate uterus. It includes the affect on fertility and gestational performance, diagnostic strategies,