Ruptured pyosalpinx following a fetal reduction procedure

Abstract

Pyosalpinx is an accumulation of pus in a fallopian tube. The conditions under which a pyosalpinx can occur vary greatly. Although pyosalpinx has been reported during controlled ovarian hyperstimulation for in vitro fertilization and embryo transfer (IVF-ET) [1], it has also been reported in a 13-year-old virgin [2] and after uterine arterial embolization [3]. A 30-year-old woman with a history of a right salpingectomy performed because of a tubal pregnancy before 20 weeks of gestation visited the CHA Fertility Center in March 2008 for IVF-ET. Left tuboplasty was performed by laparoscopy after 1 cycle of IVF-ET and thawed ET had failed. Three embryos were transferred after an additional IVF cycle and the patient became pregnant. Transvaginal ultrasound-guided selective abortion of monochorionic diamniotic (MCDA) twins was performed under analgesia with fentanyl at 8 weeks of gestation because of a quadruple pregnancy. The patient presented with generalized weakness after the procedure. The following day, the patient presented with chills and myalgia. Her body temperature was 37.6 °C and lower abdominal rebound tenderness was present. Leukocytosis was evident by a leukocyte count of 12620 cells/μL (segmentation 95.0%) and the patient's C-reactive protein concentration was 5.96 mg/dL. Blood, cervical, and urine cultures were obtained and intravenous antibiotics (cephalosporin andmetronidazole) were administered. The following day, the patient's diffuse abdominal pain was aggravated. A follow-up ultrasound detected 2 fetuses with heart beats and an enlarged left ovary (5.7×3.7 cm) that showed intact blood flow from the ovarian vessels. Fluid in the pouch of Douglas was also noted. Brown pus and debris were found on explorative laparoscopy of the pelvic cavity. On close inspection, the left salpinx was ruptured and yellowish pus was found to be leaking from the lesion. After aspiration of the pus for peritoneal fluid cytology, the left salpinx was excised with suction and irrigation and a drain was inserted into the pelvic cavity. On the first postoperative day the patient's body temperature and leukocyte count had decreased, and her abdominal pain had subsided. Culture results for the pus, blood, urine, and cervix showed no microbial growth. Many neutrophils were present in the peritoneal fluid cytology specimen. By the sixth postoperative day, the patient had made an uneventful recovery and left the hospital with the 2 remaining fetuses healthy and viable. An immunocompromised status due to poor general health can cause a latent pathogen in a hydrosalpinx to precipitate a pyosalpinx. The cause is uncertain in the present case. Clinicians should consider the possibility of pyosalpinx in the differential diagnosis of patients presenting with symptoms of abdominal pain and fever following fetal reduction.