Septic Abortion at 17 Weeks Gestation after Radical Trachelectomy and Transabdominal Cerclage: A Case Report

Abstract

Septic abortion can lead to severe maternal morbidity and mortality. The management of septic abortion can be complicated by a history of radical trachelectomy and transabdominal cerclage placement. A 33-year-old G1P0 at 17 weeks and 6 days gestation presented in severe septic shock after being diagnosed 6 days prior with previable rupture of membranes at an outside hospital and managed expectantly. History was notable for cervical adenocarcinoma status post radical trachelectomy and transabdominal cerclage placement. Due to uterine occlusion from the cerclage, the patient underwent emergent uterine evacuation via an abdominal approach. The risks and benefits of expectant management of pre-viable rupture of membranes in patients with abdominal cerclage should be weighed very cautiously. Among women with abdominal cerclage for whom uterine evacuation is indicated, a transabdominal approach may be necessary.

1. Introduction

Septic abortion is a serious uterine infection occurring shortly before, after, or during spontaneous or induced abortion. Prompt recognition and treatment of septic abortion is essential to reduce maternal morbidity and mortality, especially in cases complicated by septic shock. The cornerstones of septic abortion treatment are antibiotic therapy and uterine evacuation. Herein, we describe a case of septic abortion occurring in a patient who had previously undergone radical trachelectomy (RT) and placement of a transabdominal cerclage (TAC).

In patients with early-stage cervical cancer who desire future fertility, treatment via RT may be an option to preserve fertility [1,2,3,4]. Pregnancy after trachelectomy has been associated with increased risk of abortion and premature birth [1,4,5], though prophylactic TAC placement can be considered to help reduce these risks [6]. In the event uterine evacuation becomes indicated, the resulting uterine occlusion that occurs after RT and TAC placement may limit or completely inhibit the ability to perform uterine evacuation through a vaginal approach and thus necessitate evacuation abdominally via a hysterotomy [6].

We describe the diagnosis and management of septic abortion with maternal septic shock after previable rupture of membranes at 17 weeks gestation in a patient who had previously undergone RT and TAC placement. Patient consent for publication was obtained.

2. Case Presentation

A 33-year-old G1P0 at 17 weeks and 6 days gestational age by in vitro fertilization presented to the emergency department with symptoms of uncontrollable rigors and abdominal cramping. She was seen by an outside provider 6 days prior and was diagnosed with previable rupture of membranes at that time. Given her strong desire to continue the pregnancy, she opted for expectant management and was discharged on amoxicillin and azithromycin. Prior history is notable for stage 1B1 adenocarcinoma of the cervix treated with fertility-sparing RT and TAC. Other abdominal surgeries included left salpingectomy for hydrosalpinx and diagnostic laparoscopy for infertility workup.

Upon presentation to the emergency department, she met sepsis criteria with tachycardia, hypotension, fever of 40 degrees Celsius, leukopenia of 2.7, and metabolic acidosis. She had blood cultures drawn, was promptly started on piperacllin/tazobactam for broad-spectrum antibiotic coverage, and was fluid resuscitated with lactated ringers. Upon pelvic examination, her cervical OS was noted to be closed and a moderate amount of white milky discharge was visualized. Septic abortion was highly suspected as the etiology of her presentation.

Consideration was given to transferring the patient to the hospital where she had been receiving routine obstetric care; however, she was too hemodynamically unstable to safely undergo transfer. While still in the emergency room, her hypotension worsened to 70s/40s despite fluid resuscitation and she was started on norepinephrine. The patient and her partner were thoroughly counseled on the severity of her presentation, the heightened risks of maternal morbidity and mortality, and the significant unlikelihood of the fetus surviving to a viable gestational age.

After consultation with maternal fetal medicine, gynecology oncology, and complex family planning providers, recommendation was made for immediate surgical management. Given the patient’s stenotic os, she would have required cervical preparation; however, since she was hemodynamically unstable, she was not a candidate for osmotic dilators. Intraoperatively, again, her lower uterine segment/remaining cervical tissue was too closed for manual dilation, and an abdominal approach was elected. A gynecologic oncology surgeon was consulted intraoperatively for consideration of cerclage removal abdominally but, after examination, recommended leaving the cerclage in situ due to the risk of significant bladder injury that may occur during removal. To reduce the risk of hemorrhage, she was pre-medicated with 1 g of tranexamic acid prior to the procedure. A 4 cm vertical hysterotomy was made roughly 3 cm above the cerclage and the fetus was delivered intact in breech presentation. The procedure was complicated by an estimated blood loss of 900 cc due to uterine atony that was treated with bimanual massage, methylergonovine, carboprost tromethamine, and one unit of packed red blood cells. She tolerated surgery well and was transferred to the recovery room off pressor support. She did, however, become hypotensive in the recovery unit, requiring reinitiation of pressor support and transfer to the intensive care unit (ICU).

Overall, the patient recovered well in the ICU. She received a second unit of packed red blood cells and continued fluid resuscitation. Serial laboratory analysis showed a peak of her leukocytosis to 37 on post-operative day 1 with subsequent downtrend and mild electrolyte abnormalities that were corrected daily. Creatinine was always stable and within a normal range. She was eventually weaned from pressor support on post-operative day 2 and continued to be afebrile since her initial presentation. On post-operative day 2, her initial blood cultures grew Escherichia coli, at which time her broad-spectrum antibiotics were narrowed to cefazolin. Histology of the surgical specimen revealed numerous polymorphonuclear inflammatory cells surrounding chronic villi (Figure 1).

Regarding other post-operative milestones, she had adequate pain control, appropriate vaginal bleeding, and a smooth return to bowel and bladder function. Her abdominal incision required dressing changes during the first few days due to copious serosanguinous discharge likely due to edematous tissue from the third spacing of fluid, which eventually resolved. On post-operative day 4, the patient was deemed appropriate for discharge with oral pain medications and cefadroxil 1 g daily for 14 days as well as outpatient follow-up. She was counseled on the importance of an interpregnancy interval of at least 18–24 months due to the risk of uterine rupture after cesarean section [7,8]. The consideration of utilizing a gestational carrier for future pregnancy was also discussed. She desired a private burial for the evacuated products of conception, which were released to her by pathology.

The patient was seen for follow-up with gynecology after discharge from the hospital. Her post-operative symptoms included residual abdominal cramping and incisional tenderness, both of which self-resolved with time.

3. Discussion

Septic abortion can lead to life-threatening maternal illness. Prompt recognition of septic abortion and treatment with antibiotic therapy and uterine evacuation are crucial to reduce maternal morbidity and mortality. In this case, the management of septic abortion was complicated by the patient’s history of RT with subsequent TAC placement.

After rupture of membranes, the risk of ascending intraamniotic infection increases. In this case, it is likely that several factors contributed to this patient’s profound septic presentation. The abdominal cerclage may have served as a nidus for ascending infection and thus increased her risk for the initial development of infection as well as the progression to septic shock. Once an intraamniotic infection was present, the uterine occlusion from an abdominal cerclage may also have decreased the likelihood of abortion occurring spontaneously, thus eliminating the body’s ability to expel the source of infection. These factors were likely additive in increasing this patient’s risk of progression to septic shock.

It is commonly accepted that cesarean delivery is the appropriate mode of delivery for pregnancy in the third trimester after RT and TAC; however, there is little data available in the literature to guide management in the second trimester. Our literature review revealed two case reports that describe successful vaginal abortion in the second trimester after RT and TAC; however, both required cerclage removal and neither was in the case of septic abortion [9,10]. A large retrospective study of 142 patients with TAC for varying indications reported three cases of successful dilation and evacuation with a TAC in situ; however, all patients had obstetric indications for TAC placement without RT, and none of the patients presented with septic abortion. The study also included one patient in the second trimester after RT and TAC who underwent classical cesarean delivery for previable rupture of membranes [11].

While the Society for Maternal-Fetal Medicine recommends pregnancy loss in the setting of TAC (not specific to RT status) be managed with dilation and curettage or dilation and evacuation with TAC in situ, or via usual obstetric management after removal of TAC [12], a large literature review study of management of pregnancy after RT recommended cesarean section for women who have undergone RT with TAC placement who suffered second-trimester loss. Their reported rationale was to avoid lacerating the residual cervix and to avoid TAC removal [6]. There are several reported cases of cervical laceration caused by vaginal delivery in pregnancy after radical trachelectomy with abdominal cerclage [13].

While this patient received care in a state that protects abortion access, the overturning of Roe v. Wade has dramatically altered how providers care for pregnant women in the United States. Though a larger discussion is outside the scope of this article, this case demonstrates the potential morbidity and mortality of mid-trimester loss, the need to maintain a high index of suspicion for septic abortion, and the importance of prompt intervention.

4. Conclusions

After rupture of membranes at a previable gestational age, the likelihood of a viable, live-born infant is exceedingly low. Furthermore, maternal morbidity and mortality from previable rupture of membranes, especially when complicated by septic abortion, must be considered. The risks and benefits of expectant management of rupture of membranes at a pre-viable gestational age in patients with abdominal cerclage should be weighed very cautiously, and the most optimal method of uterine evacuation should be given significant consideration.