Septic abortion complicated by serous meningitis

SEPTIC ABORTION COMPLICATED SEROUS MENINGITIS* -f

BY

J. HUNTER, CAPTAIN (MC) USN, AND DONALD P. BERNARD, LIFJJTENANT COMMANDER HENRY

(From

the U. S. Naval

Hospital,

Philadelphia,

(MC)

USN

Pa.)

LTHOUGH serous meningitis has been described and discussed in the netirological literature for many years, it has not, to our knowledge, appeared in the obstetrical literature. Its predilection for young women and the high abortion rate associated with it make it an entity of interest to the obstetrician-gynecologist as well as the neurologist and neurosurgeon. Also known as pseudotumor cerebri, pseudoabscess, and benign intracranial hypertensioli, the etiology of this condition remains obscure. The diagnosis- depends on an increased cerebral spinal fluid pressure and symptoms secondary to increased pressure without any demonstrable lesion. Foley1 reported in 9 women with this condition the following gestational results : 14 normal pregnancies, 2 stillbirths, and 8 abortions, or a fetal loss of 40 per cent. He postulated a hormonal or fluid imbalance as the cause. In the following case the condition coincided with hospitalization for a septic missed abortion.

A

A 2%year-old Negro woman was admitted to the Naval Hospital on Nov. 12, 1956, with the complaints of fever and a foul, bloody vaginal discharge. The last normal menses had been July 28. She had noted slight breast soreness and nausea in August and a 10 day episode of spotting in early September. On September seventeenth she experienced what she described as a sudden gush of “bloody water.” She was seen in the outpatient clinic on September 28 when the uterus was noted to be approximately the size of an 8 weeks’ gestation. The cervix was closed and no discharge was seen. Because of her history she was advised to return every two weeks for examination. On November 12 she noted a foul, bloody vaginal discharge which required four pads during the day. She presented herself at the hospital and was admitted. The patient was a gravida vi, para iv, who had had one abortion. The past history was noncontributory except for a previous admission at this hospital in May, 1956, when a missed abortion was evacuated by curettage. Physical examination on admission was negative except for a uterus enlarged to the size of a 6 weeks’ gestation, a temperature of 101” F. and a foul, bloody uterine discharge. The adnexa were negative. The patient did not complain of headache or visual disturbances and a careful neurological examination was not done at this time. Urinalysis was negative. A leukocytosis of 22,800 was present, with neutrophila 82, lymphocytes 12, and band forms 6. The hemoglobin was 12.2 Gm., erythrocytes 3.88 million and the hemaher previous admission she was known to have a sickle-cell trait, but no tocrit 35. From sickling was noted on smears. The patient denied any instrumentation or interference. A diagnosis of infected missed abortion was made and she was started on penicillin and *Presented of

the

tThis article Navy.

at a meeting is not

to be

of the Obstetrical construed

Society

as necessarily

63

of Philadelphia, reflecting

the

Jan. views

of

3. 1957. the

Department

streptomycin. On the third hospital day she was still febrile and the odor of the dis charge still strong. Anaerobic cultures were negative for Clostridium welchii organisms but E. coli had grown out of the aerobic cultures. ;2 scout film of the pelvis was negative for foreign body. On pelvic examination the cervix was found to be open and a 1 by 1 by 1 cm. mass of putrid placental tissue was removed from the cervical canal. The patient complained of a frontal headache for which she was given aspirin and codeine with some relief. Her temperature continued to be 101.102” F. On November 15, with continued complaints of frontal headache, a neurological lateral nystagmus to the right, and :I examination was made, and bilateral papilledema, stiff neck were noted. Neurological consultation confirmed these findings. A spinal tap The cell count was 300 lymphocytes. revealed 330 mm. pressure and slightly cloudy fluid. An angiogram was negative for a frontal No polymorphonuclear leukocytes were found. lobe lesion. A tentative diagnosis of right cerebellar abscess was made and intravenous Terramycin therapy begun. On November 16 a burr hole was made in the right occipital bone and a ventricular tap decompression was carried out. The posterior fossa was the posterior lip of the foramen magnum ronguered away. The dura was under pressure. Cerebellar explorations demonstrated no abscess on either The dura was opened in the midline and the arachnoid punctured. A gush pressure was obtained. The wound was closed. The fluid obtained had the characteristics as the spinal tap on the previous day. Cultures were negative Micrococcus pyogenes which was felt to bc a contaminant. The disappeared operative

patient made an uneventful and she became afebrile. day and she was discharged

recovery. The uterine discharge and the headache The papilledema disappeared by the eighth postto be followed in the outpatient clinic.

On December 13, the patient was seen in the examination showed normal findings, and the eye 20 she experienced a normal menstrual period.

References 1. Foley, J.: Brain 2. Davidoff, L. M.:

78: 1, 1955. Neurology 9: 605,

by means of exposed with noted to be right or left. of fluid under same cellular exeept for

1956.

clinic. grounds

She was asymptomatic, were normal. On

pelvic December