Hematosalpinx: an unusual complication after medical abortion with oral mifepristone and misoprostol

Abstract

We report a case of unilateral hematosalpinx after medical abortion with oral mifepristone/misoprostol, a technique being increasingly used in current obstetric practice in Taiwan. A 36 year-old pregnant woman, gravida 3 para 2, attended for medical abortion counseling at 6 weeks' gestation. She had previously undergone laparoscopic enucleation of a left ovarian endometrioma and pelvic adhesiolysis, and had subsequently had two Cesarean sections for obstetric indications. Transvaginal ultrasonographic examination showed a viable intrauterine embryo of compatible gestational age and unremarkable bilateral adnexa. After thorough counseling, the couple elected to undergo medical abortion with oral mifepristone (600 mg) followed 48 hours later by 400 µg of oral misoprostol. She returned 1 week later for a follow-up ultrasound scan and complained of abdominal cramping. On ultrasound examination the intrauterine gestational tissue had been expelled completely but a large (7 cm) heterogeneous echogenic left adnexal mass (Figure 1), thought to be a hematosalpinx, was noted. Color Doppler flow mapping showed no intratumoral blood flow with peripheral low-velocity and high-resistance flow signals (resistance index (RI) = 0.78). Her serum CA125 level was elevated, at 887 U/mL. The left hematosalpinx resolved completely 4 months later. At the time of writing she has been followed up for over a year and has had an uneventful clinical course. Follow-up ultrasonographic examination 1 week after medical abortion showed a heterogeneous echogenic left adnexal mass (M). Mifepristone (RU-486), an antiprogestin, has more than double the binding affinity for progesterone receptor as does progesterone itself1. The actions of mifepristone on the reproductive system make it a useful agent for abortion. Misoprostol, an orally active and inexpensive prostaglandin E1 analog, increases uterine activity especially when used in conjunction with mifepristone. Current evidence suggests that either 200 mg or 600 mg mifepristone followed 36 to 48 hours later with 400 µg of oral misoprostol or 800 µg of vaginal misoprostol are effective for abortion at up to 49 days' gestation. Mifepristone affects not only a woman's reproductive system, but her cardiovascular, digestive and central nervous systems as well2. Patients who opt to have medical abortion should be counseled about the side effects of this combination regimen. The best known adverse effects are cramping and nausea, but other side effects such as vomiting, diarrhea, headache, dizziness and fever or chill occur in up to 15% of patients3. Two-thirds of the patients with cramp may need pain medication, but opiates are required in less than 2%. Most women will bleed for 13–15 days, and a few (less than 10%) will bleed for over 30 days4. The incidental findings of a huge adnexal mass with abnormally high serum CA125 levels in our case after medical abortion with oral mifepristone and misoprostol are unusual. The diagnosis was made by comparing pre- and postabortion ultrasonographic findings (indicating an acute lesion) and the appearance of the lesion with its elongated shape and fibrin-like contents. Pregnant women and gynecologists who decide to terminate an unwanted pregnancy with this technique need to familiarize themselves with its efficacy and complications. Acute hematosalpinx appears to be a rare complication, but one which should be borne in mind if there is lower abdominal pain after medical termination of pregnancy. S. K. Lin*, E. S. C. Ho*, Y. J. Chen*, * Department of Obstetrics and Gynecology, Taichung Veterans General Hospital, 160, Section 3, Taichung-Kang Road, Taichung 407, Taiwan, R.O.C.