Pelvic abscess in the second half of pregnancy after oocyte retrieval for in-vitro fertilization: Case report

Jan den Boon1,4, Catharina E.J.M. Kimmel2, Hélène T.C. Nagel3 and Jos van Roosmalen3

1 Department of Obstetrics and Gynaecology, Groene Hart Hospital, Graaf Florisweg 77–79, 2805 HH Gouda, 2 Department of Obstetrics, Neonatology and Gynaecology, University Hospital Utrecht, Heidelberglaan 100, 3584 CX Utrecht and 3 Department of Obstetrics, Leiden University Medical Centre, Albinusdreef 2, 2300 RC Leiden, The Netherlands


    Abstract
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 Abstract
 Introduction
 Case report
 Discussion
 References
 
We describe a very late manifestation of pelvic abscesses after oocyte retrieval for in-vitro fertilization (IVF). In a twin pregnancy achieved after intracytoplasmic sperm injection, rupture of bilateral ovarian abscesses occurred at the end of the second trimester. An emergency laparotomy was necessary because of an acute abdomen. This complication led to severe maternal and neonatal morbidity, preterm birth and neonatal death. The rare occurrence of acute abdomen in pregnancy due to pelvic infection and the non-specific symptoms of a pelvic abscess after oocyte retrieval for IVF are discussed.

Key words: complication/endometriosis/in-vitro fertilization/pelvic abscess/pregnancy complication


    Introduction
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 Abstract
 Introduction
 Case report
 Discussion
 References
 
Pelvic infection is a rare but well-known complication following transvaginal oocyte retrieval for in-vitro fertilization (IVF) and embryo transfer. The reported incidence in large series was <1% (Bergh and Lundkvist, 1992Go; Bennett et al., 1993Go; Dicker et al., 1993Go; Ashkenazi et al., 1994Go). In less than half of these cases a pelvic abscess develops. A pelvic infection becomes clinically evident within hours up to a few days after oocyte retrieval. The time from oocyte retrieval to the manifestation of a pelvic abscess is much longer. In the majority of cases, diagnosis will be made within 3 weeks after oocyte retrieval but an interval of 56 days has been reported (Bennett et al., 1993Go; Younis et al., 1997Go ). In most cases patients have a history of endometriosis, pelvic inflammatory disease (PID), pelvic adhesions or pelvic surgery (Howe et al., 1988Go; Bennett et al., 1993Go; Dicker et al., 1993Go; Younis et al., 1997Go).

Pregnancy is said to protect against pelvic infection. However, we describe a case of a very late manifestation of pelvic abscesses following oocyte retrieval in a twin pregnancy. The sequelae of a ruptured ovarian abscess at advanced gestational age, as in this case, can be severe.


    Case report
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 Abstract
 Introduction
 Case report
 Discussion
 References
 
The patient was a 36 year old gravida 2 para 1.

In 1986 she had a laparotomy for an endometrioma of the left ovary. Because of male subfertility, intrauterine inseminations (IUI) were carried out during 10 cycles with no pregnancy resulting. In 1994, she had two cycles of IVF. An endometrioma of the left ovary (40x55 mm) was detected. The procedures for ovum retrieval under prophylactic antibiotics were uncomplicated. None of the retrieved oocytes was fertilized.

In 1996, in the first cycle of IVF–intracytoplasmic sperm injection (ICSI) she conceived. The IVF and embryo transfer procedure was uncomplicated. In the third trimester intrauterine growth retardation was detected. A healthy girl of 2070 g was born at 38 weeks of gestation by secondary Caesarean section.

In 1997, she had her second IVF–ICSI procedure. Again, an endometrioma of 30x15 mm was detected in the left ovary. Because of an increased risk for pelvic infection due to her endometriosis, antibiotic prophylaxis was administered according to the protocol. The day before and on the day of the oocyte retrieval, she was given clavulanate potentiated amoxicillin and vibramycine. Vibramycine was continued on the day after the puncture.

There was no evidence of aspiration or puncture of the endometrioma. Four out of six oocytes were fertilized and two embryos were transferred on day 2. A biamniotic/bichorial twin pregnancy was the result. On several consecutive ultrasound scans the ovaries appeared normal.

During her pregnancy, she complained of intermittent low abdominal pain. Mechanical effects of the growing uterus were thought to be the reason. At 25 weeks and 4 days gestation, she was admitted to hospital because of impending preterm birth. Fenoterol i.v. was administered for tocolysis. On admission, she had a temperature of 38.0°C. White blood count was 17 700 x 106/l. Pelvic examination revealed a partially effaced cervix with 1 cm dilatation. On the third day after admission, she developed an acute abdomen with rebound tenderness and guarding.

An emergency laparotomy was performed. Pus emerged from the pouch of Douglas. After mobilizing the uterus through the mid-line incision, the pus appeared to emerge from the right ovary. Both ovaries were slightly enlarged and contained small abscesses. No cysts or endometrioma were detected. Both ovaries were adherent to the uterus. On the right side the abscess invaded the uterine wall. By multiple incisions in the capsule both ovaries were drained. A drain was placed through the abdominal wall in the pouch of Douglas. Gram staining revealed negative rods, positive cocci and leukocytes. Antibiotics were administered: clavulanate potentiated amoxicillin 1000/200 mg i.v. every 6 h. Afterwards, peritoneal cultures showed Staphylococcus aureus and mixed anaerobic bacteria, and antibiotics were adjusted accordingly.

On the same day, the patient was transferred to a tertiary referral centre with neonatal intensive care facilities. Fetal heartbeat of both fetuses was uncompromised. She progressively went into labour and at 26 weeks of gestation gave birth to two boys, both in cephalic position. The first had a birthweight of 876 g with Apgar score 3 and 7 after 1 and 5 min. The second had a birthweight of 915 g with Apgar 1 and 3.

The mother developed pulmonary oedema because of hypoalbuminaemia and underwent a re-laparotomy on the fifth day post-partum because of clinical signs of peritonitis and ileus. These conditions were not observed and no pus was found. The skin wound was left unsutured. She stayed in hospital for 3 weeks after her delivery and finally recovered well. A regular menstrual cycle has been restored.

The first boy stayed 9 weeks in hospital. He suffered from idiopathic respiratory distress syndrome (IRDS), pneumonia and he developed a post-haemorrhagic hydrocephalus due to a subependymal haemorrhage. He is now 8 months old. He has been readmitted to the hospital several times because of respiratory and feeding problems. His neurological development, however, is normal.

The second boy had an IRDS grade III and a bilateral intraventricular haemorrhage leading to a post-haemorrhagic hydrocephalus. He appeared to have severe brain damage. No spontaneous respiration could be restored and he died 9 weeks post-partum.


    Discussion
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 Abstract
 Introduction
 Case report
 Discussion
 References
 
Ultrasound-guided transvaginal aspiration of follicles for the recovery of oocytes is the method of choice in most IVF–embryo transfer programmes. Before the introduction of this technique, ovarian abscess was almost always part of a tubo-ovarian abscess following PID.

Direct inoculation of vaginal micro-organisms is thought to be the cause of pelvic infection following oocyte retrieval, because no pelvic infection was reported in large series with laparoscopic or abdominal oocyte retrieval (Bennett et al., 1993Go). Anaerobic opportunists of the vagina are found to be aetiological agents in pelvic abscesses after transvaginal oocyte retrieval. Escherichia coli, Bacteroides fragilis, Enterococcus and Peptococcus are commonly found microorganisms (Bennett et al., 1993Go; Dicker et al., 1993Go).

Patients who suffer from ovarian abscesses almost always have a history of salpingitis, endometriosis, pelvic adhesion, hydrosalpinx or pelvic surgery (Bennett et al., 1993Go; Dicker et al., 1993Go). Prophylactic antibiotics during oocyte retrieval are recommended in patients at increased risk, but cannot prevent pelvic infection in all patients (Bennett et al., 1993Go; Younis et al., 1997Go).

The time between oocyte retrieval and the manifestation of pelvic infection is generally some days up to 1 week. The manifestation of an ovarian abscess varies. Intervals from 1 week up to 56 days have been described. A manifestation in the second trimester of pregnancy has not been described. The abscess must have had a silent period in our case. On laparotomy the ovaries were only slightly enlarged. The bilateral appearance of abscesses suggests the existence of several very small endometriomata, which were too small to detect with ultrasound.

Treatment of a pelvic abscess varies according to the clinical situation. Antibiotic treatment alone has been applied successfully. Drainage of the abscess through culdotomy or through laparoscopy or laparotomy is the first method of choice. Successful treatment and ongoing pregnancies have been described, as well as a severe case requiring hysterectomy and bilateral salpingo-oophorectomy. (Howe et al., 1988Go).

Pregnancy is said to protect against pelvic infections. Clinicians are therefore unlikely to suspect a pelvic abscess as a cause of an acute abdomen in pregnancy. The first signs of the disease are sometimes mild and not specific (Younis et al., 1997Go). Laboratory findings may not be conclusive. A delayed presentation and advanced gestational age can lead, as in our case, to severe sequelae, such as several laparotomies, preterm birth and perinatal mortality and morbidity.

After IVF–embryo transfer, one should be aware of the possible existence of an ovarian abscess in a patient with low abdominal pain, tender adnexae or fever of unknown origin. Accurate diagnosis and subsequent intervention may prevent an acute abdomen due to a ruptured abscess.


    Notes
 
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    References
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 Abstract
 Introduction
 Case report
 Discussion
 References
 
Ashkenazi, J., Farhi, J., Dicker, D. et al. (1994) Acute pelvic inflammatory disease after oocyte retrieval: adverse effects on the results of implantation. Fertil. Steril., 61, 526–528.[ISI][Medline]

Bennett, S.J., Waterstone, J.J., Cheng, W.C. et al. (1993) Complications of transvaginal ultrasound-directed follicle aspiration: a review of 2670 consecutive procedures. J. Assist. Reprod. Genet., 10, 72–77.[ISI][Medline]

Bergh, T. and Lundkvist, O. (1992) Clinical complications during in-vitro fertilization treatment. Hum. Reprod., 7, 625–626.[Abstract]

Dicker, D., Ashkenazi, J., Feldberg, D. et al (1993) Severe abdominal complications after transvaginal ultrasonographically guided retrieval of oocytes for in vitro fertilization and embryo transfer. Fertil. Steril., 59, 1313–1315.[ISI][Medline]

Howe, R.S., Wheeler, C., Mastoianni, L. et al. (1988) Pelvic infection after transvaginal ultrasound-guided ovum retrieval. Fertil. Steril., 49, 726–728.[ISI][Medline]

Younis, J.S., Ezra, Y., Laufer, N. et al. (1997) Late manifestation of pelvic abscess following oocyte retrieval, for in vitro fertilization, in patients with severe endometriosis and ovarian endometriomata. J. Assist. Reprod. Genet., 14, 343–346.[ISI][Medline]

Submitted on March 23, 1999; accepted on May 28, 1999.





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