Uteroperitonial Fistula Secondry to Puerperal Sepsis Following Home Delivery

UTEROPERITONEAL FISTULA SECONDARY TO PUERPERAL SEPSIS FOLLOWING HOME DELIVERY
Abhang Prabhu*, Alka Gupta**, Shashank Parulekar***
*Former Registrar, Presently, Lecturer, N. Wadia Maternity Hospital; ***Associate Prof.; ***Prof.; Dept. of Ob. and Gy, KEMH, Seth GS Medical College.

Pyometra, a collection of purulent material in the uterus, is an uncommon gynaecologic entity. We report a case of spontaneous rupture of uterus following pyometra secondary to puerperal sepsis. Patient presented with acute abdomen and laparotomy revealed uterine with free pus in the peritoneal cavity.
INTRODUCTION
Pyometra, a collection of purulent material in the uterine cavity, is uncommon, with a reported incidence of 0.5% of gynaecologic patients. [1] Spontaneous perforation of the uterus into the peritoneal cavity is a rare complication of pyometra. We report a case of patient who had an acute abdominal condition as a result of pyometra complicated by spontaneous uterine perforation following puerperal sepsis.
CASE HISTORY
40 year old, G3 P3 L3, post delivery 6 weeks, presented to casualty of KEMH on November, 1997 with pain in abdomen and fever for 4 weeks. Patient delivered at home on 21st September, following a prolonged labour (> 24 hours), a male child of large size (weight not known). Child died on day five of neonatal sepsis.

Patient developed fever and pain in abdomen 10 days after delivery however, initially neglected the symptoms. After seven days patient had high grade fever with gradual abdominal distension. She was given some Ayurvedic medicine without any beneficial effect. Patient had vomiting and constipation for last two days.
O/E
General condition was poor, P-108/m, BP-90/60 mmHg, pallor present, febrile 100o F, oedema feet markedly present. Respiratory system revealed tachypnoea (20/min), harsh breath sounds. Cardiovascular system revealed no abnormality. On per abdominal examination there was distension with generalised tenderness, no guarding rigidity and bowel sounds were absent. Per speculum examination showed cervix flushed with vagina, without any discharge. On internal examination uterine size could not be made out. There was an 8 cm size mass in left fornix and cervix was tightly closed.
Investigations
Hb - 6 gm%, WBC - 21,050/c.mm (P91/L09), Blood group - A+ve. FBS - 105 mg%, PLBS - 130 mg%, BUN - 32 mg%, S. Electrolytes - Normal, Creatinine - 1.4 mg%, SGOT - 25, SGPT - 30.

X-ray abdomen with both domes of diaphragm showed dilated bowel loops suggestive of intestinal obstruction. X-ray chest showed raised domes of diaphragm. ECG - Normal.

Ultra sonography of pelvis revealed free fluid in peritoneal cavity with a large left sided tubo ovarian mass. Normal size uterus with no signs of perforation. CT scan revealed uterine rupture with utero peritoneal fistula with intra peritoneal fluid collection.
Management
Patient’s general condition was improved by giving intravenous fluids and two units of blood. Patient was started on intravenous antibiotics (cefotaxim, amikacin, metrogyl). A high risk consent was obtained and the patient was taken up for an exploration under balanced General Anaesthesia with continuous cardiorespiratory monitoring. A vertical midline incision, extending from symphysis pubis to 4 cm above the umbilicus was taken. On opening the abdomen, copious amounts of foul smelling purulent discharge was seen filling up the entire peritoneal cavity. The bowel loops were distended and plaques of purulent discharge were found to be adherent to the bowel serosa. Multiple adhesions were also present. Continuous suction of the peritoneal cavity was carried out to help visualisation of abdominal viscera and evacuation of purulent discharge. The purulent material was collected and sent for aerobic and anaerobic culture medium.

We found a gangrenous uterus with multiple adnexal adhesions. The posterior fundal aspect of the uterus showed a large 3.5 cm irregular perforation. On left side there was densely adherent tubo-ovarian mass of 10 cm diameter. The other organs viz. bowel, gall bladder, liver, lesser sac, spleen and appendix were normal.

In view of above mentioned findings, total abdominal hysterectomy with a (R) Salpingo-oophorectomy was carried out. Due to extensive adhesions and the presence of tubo-ovarian mass. On the left side the difficulty was faced during dissection. Intra-operatively, the patient was given two units of blood.
Postoperative Condition
Patient was not extubated and required respiratory support in intensive care unit for 3 days. In order to maintain the blood pressure patient needed dopamine support (5 ml/hr).

Pus culture showed Klebsiella infection, sensitive to preoperative broad spectrum antibiotics and hence they were continued for 14 days. Suture removal was done after 2 weeks and patient had burst abdomen following it. The defect was sutured in a single layer by using a non adsorbable suture material with tension sutures. There was no evidence of any intra peritoneal collection. Wound swab showed pseudomonas organism and hence was shifted to piperacillin, metrogyl combination. 2 weeks later patient went into renal failure needing intraperitoneal dialysis. Patient recovered from it however, had sudden death on post operative day 32 due to pulmonary embolism. Post mortem examination revealed saddle shape embolus in pulmonary artery bifurcation. There was no evidence of intra peritoneal abscess.
Histopathology
Histopathology of the operative specimen revealed only Inflammatory changes with Polymorphonuclear infiltration of the endo-myometrium. There was no malignancy.
DISCUSSION
Uterine pathology leading to peritonitis is uncommon condition. Pyometra is generally seen secondary to malignancies, forgotten IUD’s, D and C, cervical cauterization, conization, amputation and PID. [2] In most cases the pyometra drains intermittently via the cervix which is likely to be the path of least resistance. Spontaneous rupture of the uterus allowing drainage of the pyometra into the abdominal cavity is rare but when it occurs it is commonly associated with malignancy involving the myometrium. A small number of cases have been reported where rupture occurred at the site of myomata which became infected. [3]

Histological examination in our case revealed no evidence of malignancy, myomata or other abnormality adjacent to the site of the rupture, and therefore no obvious predisposing factor to account for the spontaneous rupture of the uterus. It is also possible that the uterus may have been previously perforated during difficult home delivery conducted by non trained personal. The cause of this rupture is uncertain and the other reason one can only postulate is that the cervix was so tightly stenosed secondary to infection that it provided greater resistance to the outflow of pus than did the myometrium itself.

With perforation of the pyometra, the infected contents of the uterus are released into the peritoneal cavity where the spill may remain localised within the pelvis or disseminate throughout the peritoneal cavity. A variety of clinical presentation result, ranging from the pelvic mass to peritonitis with shock. Regardless of the clinical presentation, a perforated pyometra necessitates early surgical exploration and broad-spectrum antibiotic therapy. [4] Inspite of early clinical diagnosis and its confirmation on CT scan with appropriate management with good post operative care our patient died. In many cases it is shown that the multiple other medical problems make such patient a poor operative candidate. As a result, despite aggressive care and early intervention such patients generally succumb to death.
ACKNOWLEDGEMENT
The authors are grateful to Dr. Mina Bhattacharya, Professor and Head, Dept. of Obstetrics and Gynaecology, Seth GS Medical College and Dr. PM Pai, Dean, KEM Hospital for permission to publish hospital data.
REFERENCES

Hosking SW. Spontaenous perforation of a pyometra presenting as generalized peritonitis. Postgraduate Medical Journal 1985; 61 : 645-46.
Palep MH, Shivade S, Dhamankar S, Shenoy SG. An unusual case of pyometra. Bombay Hospital Journal 1997; 39 : 1.
Parkinson DJ, Alderman B. Spontaneous rupture of the uterus associated with pyometra. Postgraduate Medical Journal 1985; 61 : 73-4.
Sussman AN, Boyd CR, Christy RS, Rudolph R. Pneumoperitoneum and an acute abdominal condition caused by spontaneous perforation of a pyometra in an elderly woman : A case report. Surgery Feb. 1989; 105 (2 Pt 1) : 230-1.

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