Group A streptococcus septicaemia after thermal ablation of the endometrium for menorrhagia

Authors


*Correspondence: Dr J. Kessler, Department of Obstetrics and Gynaecology, A˚lesund Hospital, A˚lesund 6026, Norway.

Case report

A 38 year old woman had a three-year history of menorrhagia. Her periods were regular. A copper intrauterine contraceptive device had been removed in the past because of menorrhagia and she had subsequently been sterilised. Previously, she had had a Bartholin's abscess and had been treated for cervicitis with laser vaporisation on three occasions, the last time being in 1998. She had four uncomplicated full term normal deliveries. As a child, she had meningitis and her only medication was beta mimetics to treat asthma.

For several years, she had been anaemic and had been treated with iron tablets and tranexamic acid. This treatment did not reduce the menorrhagia and her general practitioner referred her to the hospital. Gynaecological examination was normal. Vaginal ultrasound revealed a uterus of normal size without fibroids and normal ovaries. Endometrial aspiration was performed and histological examinations showed secretory endometrium. Treatment was discussed and the options considered were the levonorgestrel intrauterine system and thermal ablation of the endometrium. She elected thermal ablation. The procedure was carried out five months after her first out patient appointment.

Before the endometrial ablation, the vagina was cleaned with 0.1% chlorhexidine solution and 20 ml of 0.25% bupivacaine was given as a paracervical block. The cervix was dilated to 5 mm with Hegar dilators and the uterine cavity was noted to be 8 cm long. The ablation system (Thermachoice, Fa. Gynecare, Menlo Park, California, USA) was prepared and inserted into the uterine cavity in the standard manner. The ablation cycle was carried out without any problems and the woman was discharged 20 hours after the procedure.

Thirty hours after the endometrial ablation, she experienced lower abdominal pain and fever. Six hours later, she was readmitted to hospital. The concentration of C reactive protein in her blood was 84 mg/ml (normal range <5 mg/ml), her platelet count was 87 × 109/L (normal range 150–450 × 109/L) and her white cell count was 3.4 × 109/L (normal range 3.5–10 × 109/L). A clinical diagnosis of pelvic infection was made and intravenous cefuroxime and metronidazole was started. During the following hours, she deteriorated with intense abdominal pain and circulatory collapse, suggesting severe septicaemia. A laparotomy was carried out five hours after her re-admission. Inspection of the abdominal cavity revealed bilaterally necrotic tubes and ovaries and a discolouration of the fundus of the uterus. A total hysterectomy and bilateral salphingo-oophorectomy was performed and all necrotic tissue was removed. A cystoscopy was carried out and ureteric stents were inserted bilaterally. The bladder mucosa was found to be haemorrhagic and discoloured in places. The abdomen was closed.

Material from the left fallopian tube and the serosa of the uterus grew group A streptococcus, sensitive to the antibiotics being prescribed. Histopathological examination showed necrosis of the endometrium and the submucosal myometrium due to the thermal ablation. Abscesses were found in the myometrium and the left ovary containing Gram-positive coccus. Both adnexae and uterus showed areas of infarction.

The woman then developed disseminated intravascular coagulation and renal failure. Vaginal examination 20 hours after the laparotomy showed necrosis of the vaginal stump and cystoscopy revealed haemorrhagic discolouration of most of the bladder mucosa. Since she had need of both continuous dialysis and major pelvic surgery, she was transferred to the regional hospital. Immediately after arrival, a cystectomy, vaginectomy, vulvectomy and a transverse colostomy were carried out. These entire organs were necrotic, as were the distal parts of the ureters. Urine was drained by bilateral ureterocutaneostomies. Due to septicaemia and disseminated intravascular coagulation, severe compartment syndromes developed in both legs and arms. Although fasciotomies were performed in all extremities, bilateral below knee amputations had to be performed in addition to a major resection of muscles of the right arm and a smaller resection of muscles in the left arm.

Following surgery, her condition gradually improved and plastic surgery reconstruction was commenced. After eight weeks of hospitalisation in the regional hospital, the woman was returned to her local hospital for further rehabilitation.

Discussion

Thermal ablation of the endometrium in the modern treatment of menorrhagia has become increasingly popular1–9. There are many advantages to using this method of ablation, which include a short learning curve, day case treatment and fewer requirements for general anaesthesia. Published studies have showed that, provided appropriate patients are selected, there is an 80% reduction in menstrual blood loss with minimal complications2–9. Most of the complications described are due to post-operative endometritis that usually responds satisfactorily to antibiotic treatment3,5,6,9. Serious infections with group A streptococcus are known to be a rare, but increasing complication of surgery, including gynaecological and obstetric operations10,11. Sepsis with group A streptococcus has been described after insertion of an intrauterine contraceptive device12, but we are unaware of any report in the literature of this complication occurring after endometrial ablation.

Whether this complication could have been prevented by prophylactic antibiotics is uncertain. There is no evidence that prophylaxis with antibiotics reduces the frequency of post-operative infections in hysteroscopic surgery, including endometrial ablation13. As far as we are aware, the published literature on thermal endometrial ablation by balloon does not recommend prophylactic antibiotics3,6,8,9.

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