Kumar M*, Shah R**, Warke HS***.
(* Junior Resident, ** Assistant Professor, *** Associate Professor, Department of Obstetrics and Gynecology, Seth G S Medical College and K E M Hospital, Mumbai, India.)
Acute pelvic inflammatory disease is an important consequence of sexually transmitted infection. The sequelae of which can result in infertility, ectopic pregnancy and chronic pain. Its true incidence cannot be known because of its inaccuracy of diagnosis. The differential of such a condition can be ectopic pregnancy, ovarian torsion, endometriosis or other surgical conditions causing acute abdomen. This case report describes one such case in which acute pelvic inflammatory disease presented as a case of acute abdomen mimicking ruptured ectopic pregnancy.
Ruptured ectopic pregnancies are a common encounter among the obstetric and gynecological emergencies. Women with ruptured ectopic pregnancy often present with amenorrhea, bleeding per vaginum and lower abdominal pain. Once ruptured the patient has tachycardia, hypotension and abdominal rigidity. Ectopic pregnancy occurs at a rate of 0.25-2 % of all pregnancies and is about 4 % in women receiving fertility treatment. Pelvic inflammatory disease can be a risk factor for ectopic pregnancies as it narrows the lumen of the tube. A tuboovarian mass that forms as a sequela of pelvic inflammatory disease usually manifests as lower abdominal pain and vaginal discharge with fever. However, the presentation can be highly variable.
A 34-year-old third gravida with previous two living issues with 6 weeks of amenorrhea presented to the emergency with sudden onset abdominal pain and vaginal bleeding since 2 days. There was no history of passage of clots. She had tachycardia and hypotension. Urine pregnancy test was done which was weakly positive. Her hemoglobin was 9.3 gm%, white blood cell count was 24,000 /mm3, platelet count was 2 lakhs/mm3 and β human chorionic gonadotropin was 420 mIU/ml. On per abdominal examination tenderness was present and on per speculum examination minimal bleeding was present. On per vaginal examination uterus was bulky, cervical os was closed. Cervical motion tenderness was present. Colpopuncture revealed straw colored fluid. Ultrasound done was suggestive of 7-8 cc of organized hematoma in the right adnexa with significant hemoperitoneum and diagnosis of ruptured ectopic pregnancy was made. Emergency exploratory laparotomy was performed. Approximately 200 ml serosanguinus ascitic fluid was seen on opening the peritoneal cavity with pus flakes within. Uterus was bulky and covered with pus flakes. Left fallopian tube and ovary were normal. Right fallopian tube was dilated, thickened approximately 7x4 cm and was congested. It was covered with pus flakes and there was shaggy necrotic material on posterior surface of the broad ligament. Right ovary was adhered to the dilated and thickened fallopian tube and ovarian surface was congested forming a tuboovarian mass. Ovary could be easily separated from the dilated fallopian tube. Right salpingectomy was done followed. Dilatation and curettage was done to exclude an intrauterine pregnancy and specimen was sent for histopathology. Post operative her vital parameters were within normal range. Histopathology of the right fallopian tube revealed acute salpingitis with no evidence of gestational sac or products of conception. The endometrium histopathology showed focal areas of Arias Stella reaction with no evidence of products of conception.
Ruptured ectopic pregnancy remains the most frequent cause of obstetric emergencies. Its diagnosis is based on the clinical symptoms and radiological findings. Many medical and surgical factors must be taken into consideration in the diagnosis of acute abdominal pain. The differential diagnosis includes acute appendicitis, pelvic inflammatory disease, ovarian torsion and ruptured ectopic pregnancy. Tuboovarian mass is a late sequela of pelvic inflammatory diseases which can be life threatening if the abscess ruptures.
The histological features of ectopic pregnancy normally include extra villous trophoblast and intraluminal chorionic villi sometimes with decidual changes in the lamina propria. Microscopic evidence of an embryo is seen in two third of such cases. However, in this case no such histological evidence was seen. Since the intraoperative picture of such a case was not like that of a ruptured ectopic, dilation and curettage was done to rule out a intrauterine pregnancy.
The histology of Arias Stella reaction includes large cells with eosinophilic cytoplasm, nuclear enlargement and hyperchromasia. Arias Stella reaction is associated with conditions in which hormonal stimulation occurs. It can be encountered during normal pregnancy or ectopic pregnancy. Arias Stella reaction on secretory endometrium is not diagnostic of intrauterine or extrauterine pregnancy. This reaction can also be seen in non pregnant patients in whom exogenous hormonal therapy is administered.
In our case focal Areas Stella reaction was diagnosed which could be attributed to an early intrauterine gestation that might have aborted during the bleeding episode.
A tuboovarian abscess manifests as an adnexal mass, elevated white blood cell count, lower abdominal pain or vaginal discharge. The risk factors for a tuboovarian abscess includes history of prior pelvic inflammatory disease, intrauterine device insertion, multiple sexual partners and tuberculosis. Bacteria associated with tuboovarian abscess are Escherichia Coli, Bacteroides fragilis, Pepto streptococcus, Chlamydia. Patients usually present with pelvic mass, abdominal pain, fever, leucocytosis, and elevated erythrocyte sedimentation rate.
Prior to the wide availability of radiological diagnosis culdocentesis was considered as a valuable clinical diagnostic tool. In this procedure a needle is inserted through the posterior vaginal fornix into the Pouch of Douglas and peritoneal fluid is obtained. The sensitivity and specificity of fluid found in culdocentesis is 66 % and 80 % respectively.
A tuboovarian abscess can be diagnosed by an ultrasound. It appears as a solid/ cystic mass or as a pyosalpinx. Computed tomography (CT) scan may be useful when a gastrointestinal pathology is suspected such as an appendicular mass. When a tuboovarian abscess is present a common finding on computed tomography is a thick walled, fluid dense mass in the adnexa often with septations. There may be anterior displacement of thickened mesosalpinx.
Initial management depends on clinical findings and ultrasound. In case of sepsis; resuscitation, administration of broad spectrum antibiotics and prompt surgery may be considered. Medical treatment of a tuboovarian abscess is associated with a high recurrence rate. A successful intravenous antibiotic must be able to enter abscess cavity and should be active against the commonest pathogen. Intravenous ceftriaxone, clindamycin, metronidazole and cefoxitin have higher abscess cavity penetration and are shown to reduce the abscess size.
Earlier diagnosis and broad spectrum antibiotics have reduced the need for surgery. No improvement in clinical condition of the patient within 24 hours of antibiotic demands surgery. Surgery is technically difficult as the tissues are fragile due to necrosis. The bowel is commonly adherent to the mass making it prone for a visceral injury. Drainage of pelvic abscess with irrigation of the abdominal cavity can be done if patient wishes to preserve fertility. An intraperitoneal drain is usually kept to allow remaining pus to drain. Laparoscopic adhesiolysis with drainage of the abscess under antibiotic cover can also be considered. Image guided drainage can also be used for management of tuboovarian abscess. It can be performed via transabdominal, transvaginal or transgluteal route.
To conclude, tuboovarian abscess requires aggressive medical therapy as rupture may result in sepsis requiring intensive therapy. Our case was similarly managed by the use of intravenous antibiotics following an exploratory laparotomy.
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Kumar M, Shah R, Warke HS. Acute Pelvic Inflammatory Disease Mimicking Ruptured Ectopic Pregnancy. JPGO 2019. Volume 6 No.3. Available from: https://www.jpgo.org/2019/03/acute-pelvic-inflammatory-disease.html