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Post Criminal Abortion Retroperitoneal Abscess

Author Information

Kulkarni S*, Parulekar SV**, Hira Priya***
(* Third Year Resident, **Professor and Head of the department, Department of Obstetrics and Gynecology; *** Associate Professor, Department of radiology, Seth GS Medical College & KEM Hospital, Mumbai, India.)

Abstract

Retroperitoneal abscess is an uncommon complication of a first trimester medical termination of pregnancy. It would be more likely after a criminal abortion. We present a rare complication of first trimester criminal abortion in the form a retroperitoneal abscess which continued to drain through the uterus vaginally. This is the first case of this occurrence in the world literature.

Introduction

Retroperitoneal infection may occur either as direct invasion from the contained organs (as in case of kidneys, ureters, pancreas, abdominal aorta, and inferior vena cava), contiguous organs (as in case of ascending colon, de­scending colon, duodenum, bladder, uterus, and rectum) or hematogenous and lymphatic spread from areas of drainage.[1-15] It may occur after a delivery or an abortion. It may follow a first trimester medical termination of pregnancy in case the uterus is perforated. It may be associated with a high mortality rate (22-46%).[16] We present a postabortal case with a retroperitoneal abscess in which the pus continued to drain through the uterus and cervix. This is the first case of this occurrence in the world literature.

 Case report

A 28 yrs old woman , P2L2A1, presented on  day 28 of evacuation of products of conception for probably missed or inevitable abortion by a nonqualified person. She had complaints of  excessive foul smelling discharge per vaginum for 25 days, and fever on and off for 1 week. On examination she was afebrile and her vital parameters were within normal limits. Mild tenderness was present in left iliac fossa. A speculum examination  showed foul smelling purulent discharge pouring out of the cervix. On bimanual pelvic examination there was vaginal warmth, a retroverted and normal sized uterus, and a firm to hard band leading from the left uterine wall to the left lateral pelvic wall. The pus was sent for microbiological studies. She was administered cefotaxime, gentamycin and metronidazole parenterally. Abdominopelvic ultrasonography (USG) showed features of endometritis and a 2×2 cm ovarian cyst on left side. Despite therapy she continued to get fever up to 400 C and pour out pus through the cervix. The pattern of discharge of the pus was unusual. There would be alternating dry days and days with abundant discharge of pus. The pus and blood culture showed no growth of any organisms. Another sample of the pus showed growth of Enterococcus fecalis, Klebsiella pneumoniae and Gram-Negative bacilli. Injectable Linezolid and Piperacillin were started according to culture and sensitivity report. The patient continued to be symptomatic with fever and discharge per vaginum with increasing tenderness in left iliac fossa. Hence computerized tomography (CT) of the abdomen and pelvis was done. It showed a retroperitoneal collection of pus with air specs. It measured 6×7cm (about 500 ml). It extended from the left kidney pushing it forwards, behind the descending colon, along the left iliopsoas region.


Figure 1. CT scan of the abdomen and pelvis. The left kidney (LK) is pushed forward by the abscess.


Figure 2. CT scan of the abdomen and pelvis. The uterus with pus, the abscess and the communication between them are seen.

Retroperitoneal drainage of abscess was done. All the loculi were broken About 400 ml of pus was removed. A large bore drainage tube was left in the abscess cavity. The cervical drainage of the pus stopped following the operation. The pus stopped draining after 6 days. The drainage tube was removed on the seventh postoperative day, and the wound was dressed regularly. The patient recovered uneventfully and was discharged on eighth postoperative day. She was well at follow up after 15 days. Repeat USG did not show any collection of pus in the left retroperitoneum. It was likely that the tract connecting the uterine cavity to the retroperitoneal space remained, and would not close down. Since closing it surgically would perhaps lead to further complications, and the patient was not keen on having another pregnancy, she was advised to use barrier contraception. She accepted that.


Figure 3. Exploration of the abscess cavity with a finger passed through an incision above the left iliac crest.


Figure 4. A wide bore drainage tube has been passed into the abscess cavity.

Discussion

The retroperitoneal space is a potential space which lies between the posterior parietal peritoneum and transversalis fascia of the posterior abdominal wall, extending superiorly to the diaphragm, inferiorly to the pelvis, and laterally to the edges of the quadratus lumborum muscles. Though it is a potential space, it can accommodate up to 2000 ml of pus.[17,18] Retroperitoneal infection may occur either as direct invasion from the contained organs (as in case of kidneys, ureters, pancreas, abdominal aorta, and inferior vena cava), contiguous organs (as in case of ascending colon, de­scending colon, duodenum, bladder, uterus, and rectum) or hematogenous and lymphatic spread from areas of drainage. A retroperitoneal abscess may spread to the iliopsoas area through the iliopsoas bursa.[19] Uterine perforation may occur during rapid dilatation of cervix and evacuation of uterine contents for performance of a first trimester termination of pregnancy. It is not very common if due care is exercised. It is more likely to happen and be associated with infection in cases of first trimester criminal abortion performed by untrained and unqualified persons. A uterine perforation may not be diagnosed when it occurs. Usually it occurs in the anterior or the posterior wall of the uterus. If it occurs in the lateral wall, it leads to the broad ligament area.[20] It would escape immediate detection if the uterine vessels are not injured. Extraperitoneal hemorrhage followed by its infection would lead to the development of a retroperitoneal abscess, as occurred in our case. Intraperitoneal hemorrhage and infection are detected early because of associated pain and local signs like tenderness, guarding and rigidity. These features are absent in case of a retroperitoneal abscess. So the onset is insidious and diagnosis late. Our patient developed vaginal discharge early, because the abscess cavity communicated with the uterine cavity through a track opening in its left lateral wall. The pus escaped periodically by overflow. But the diagnosis was missed during USG.
Retroperitoneal abscesses are often polymicrobial, and the predominant isolates are E. coli, K. pneumoniae, S. aureus, and enterococci.[21] Our patient also had polymicrobial growth from the pus. Tuberculosis can also cause a retroperitoneal abscess.[22] CT is particularly useful for evalua­tion of the retroperitoneum. It permits precise anatomic delineation of the extent of the abscess, which is useful in planning a surgical approach.[23-26] In our case the CT showed the exact extent of the abscess and even showed the communicating track between the abscess and the uterus.
Transperitoneal drainage should be avoided as contamination of the peritoneal cavity would lead to generalized peritonitis. Failure, recurrence or mortality occurs in 67%  cases with this approach. If the abscess is unilocular and the pus is relatively free of particulate matter, insertion of a pigtail catheter for drainage may be done.[27,28] If there is poor response to treatment, surgical drainage is done. It is done by a flank approach as in our case.[29] The catheter can be connected to low intermittent suction. If drainage stops suddenly, a block in the catheter is suspected, and it is irrigated gently with small quantity of normal saline. The catheter is withdrawn gradually as the abscess cavity shrinks and the drainage decreases in volume.[30]

Conclusion

Retroperitoneal abscess is a serious condition that may have few localizing signs. It may occur as a complication of perforation of a gravid uterus, especially after a criminal abortion. A high degree of suspicion aided by modern imaging techniques like CT and magnetic resonance imaging helps make an accurate diagnosis. Early diagnosis and treatment by catheter or open drainage help reduce morbidity and mortality associated with the condition.

Acknowledgement

We thank Dr Deshpande AA for extraperitoneal drainage of the abscess.

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Citation

Kulkarni S, Parulekar SV, Hira P. Post Criminal Abortion Retroperitoneal Abscess. JPGO 2014 Volume 1 Number 11. Available from: http://www.jpgo.org/2014/11/post-criminal-abortion-retroperitoneal.html