Spontaneous uterine perforation from uterine infarction: a rare case of acute abdomen

Spontaneous perforation of pyometra: a report of seven cases and review of the literature

BACKGROUND/AIMS

The spontaneous perforation of pyometra is very rare and is associated with a poor prognosis. The present study aimed to evaluate the clinical characteristics and prognostic factors for patient survival.

PATIENTS AND METHODS

We reported on 7 patients with spontaneous rupture of pyometra. We also reviewed 47 additional published cases. Thus, all 54 patients were analyzed for mortality.

RESULTS

We investigated the prognosis in 44 of 54 patients, excluding 8 patients with undocumented outcome and 2 who died of other diseases. The mortality rate was 25% (11 of 44). In univariate analysis, variables such as age, correct preoperative diagnosis, comorbidities, the presence of malignancy, and hysterectomy were not significant between surviving and deceased patients. In bacterial cultures from the peritoneal cavity, the most common etiological organisms were Escherichia coli and anaerobes such as Bacteroides and Peptococcus species. The rate of isolation of anaerobic bacteria was significantly increased in patients who died (odds ratio, 6.33; 95% confidence interval, 1.28-31.02; p = 0.04).

CONCLUSION

Antibiotic therapy for E. coli and anaerobes should be considered in patients with spontaneous perforation of pyometra.

Computed tomography findings of spontaneous perforation of pyometra

We report herein a case of spontaneous perforation of pyometra leading to diffuse peritonitis. This pathological condition is rare, and preoperative diagnosis is difficult. We were able to make the correct diagnosis preoperatively using contrast-enhanced abdominopelvic computed tomography. Both intrauterine and extrauterine fluid collections and defects of the uterine fundus were key findings, and reconstructed sagittal and coronal images were useful. In elderly female patients presenting with acute abdomen, ruptured pyometra should be considered as a possibility.

Spontaneous perforation of pyometra

Pyometra is the accumulation of purulent material in the uterine cavity. Its reported incidence is 0.01−0.5% in gynecologic patients; however, as far as elderly patients are concerned, its incidence is 13.6% [3]. The most common cause of pyometra is malignant diseases of genital tract and the consequences of their treatment (radiotherapy). Other causes are benign tumors like leiomyoma, endometrial polyps, senile cervicitis, cervical occlusion after surgery, puerperal infections, and congenital cervical anomalies. Spontaneous rupture of the uterus is an extremely rare complication of pyometra. To our knowledge, only 21 cases of spontaneous perforation of pyometra have been reported in English literature since 1980. This paper reports an additional case of spontaneous uterine rupture.

Transvaginal sonographic findings of a large intramural uterine hematoma associated with iatrogenic injury sustained at termination of pregnancy

We report a case in which a patient presented with severe right lower abdominal pain associated with nausea and vomiting 3 days after termination of pregnancy. Transvaginal ultrasonography showed a large intramural mass in the anterior aspect of the lower segment of an acutely retroflexed uterus. Computed tomography and magnetic resonance imaging findings were consistent with an intramural hematoma as a result of iatrogenic injury sustained during the preceding termination of pregnancy. The patient was managed expectantly. Systematic review of the literature confirmed that this is the first report of sonographic findings associated with an intramural uterine hematoma some days after the injury sustained at termination of pregnancy. This case supports utilization of real-time ultrasound guidance during intrauterine surgery of selected cases to decrease procedure-related morbidity.

Uterine infarctions in cynomolgus monkeys (Macaca fascicularis)

Uterine infarctions have not been reported in domestic animals, and there are few reports in the human medical literature. In a retrospective study, uterine infarctions were identified in 9 of 323 (2.8%) female cynomolgus monkeys (Macaca fascicularis) necropsied over a 13-year period. The infarctions were grossly visible, after fixation, on the serosal surface of the uterus in 2 monkeys; the remainder were first recognized in histologic sections. Histologically, the lesions consisted of well-demarcated regions of endometrial and myometrial necrosis and of hemorrhage. All affected monkeys had histologic evidence of a previous pregnancy, which included enlarged myometrial vessels with an expanded perivascular matrix. In all monkeys with uterine infarctions, there was clinical evidence of severe systemic illness, which included trauma, diarrhea, hypovolemia, or septicemia. The major pathologic findings in affected monkeys included cutaneous or skeletal muscle necrosis (n = 5), enterocolitis (n = 4), pulmonary edema or diffuse alveolar damage (n = 3), and intestinal amyloidosis (n = 1). Histopathologic evidence of intravascular fibrin thrombi in multiple organs of 5 monkeys was consistent with a diagnosis of disseminated intravascular coagulopathy (DIC). Based on these findings, it appears that uterine infarction is an uncommon finding in cynomolgus monkeys and may occur secondary to a severe systemic illness, predisposing to DIC.

V. Uterine fibroid embolization: management of complications

Fortunately, the number of complications reported after uterine fibroid embolization (UFE) is extremely low. Angiographic mishap or drug reaction are probably more common than purely UFE-related complications. However, the possibility of infection or necrosis of the uterus, with their significant attendant morbidity, is a sobering reminder that embolotherapy can have a powerful impact on the target organ(s). Knowledge of the expected time course for symptom resolution and the often confusing imaging findings shortly after UFE are critical for avoiding unnecessary delay in surgical intervention or, perhaps more important, an inappropriate rush to surgery when antibiotics alone will suffice. Other complications include alteration of uterine physiology, which may disrupt sexual function, and menstrual irregularity and even premature menopause.