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CASE REPORT
Year : 2023 | Volume
: 12
| Issue : 1 | Page : 55-57
Septic shock following operative hysteroscopy in a menopausal woman: A case report and review of the literature
Moad Belouad1, Abdelhamid Benlghazi1, Lina Belkouchi2, Yassine Bouhtouri1, Saad Benali1, Jaouad Kouach1
1 Department of Gynecology and Obstetrics, Military Hospital of Instruction Mohamed V, Rabat, Morocco
2 Department of Radiology, Military Hospital of Instruction Mohamed V, Rabat, Morocco
Correspondence Address:
Dr. Moad Belouad
Department of Gynecology and Obstetrics, Military Hospital of Instruction Mohamed V, Rabat
Morocco
Source of Support: None, Conflict of Interest: None
DOI: 10.4103/gmit.gmit_33_22
Minimally invasive gynecologic surgery such as hysteroscopy has a low risk of complications. Infections, however, are more common in the presence of risk factors such as smoking, history of pelvic inflammatory disease, and endometriosis. We report the case of a patient who underwent operative hysteroscopy without immediate complications and was admitted 2 days later to the emergency department in a severe state of septic shock. With multiple organ failures requiring admission to an intensive care unit, the patient died despite extensive antibiotic therapy and vasoactive drugs. Ascending infection can be a potentially fatal complication of hysteroscopy, even in the absence of known risk factors.
Keywords: Complications, hysteroscopy, multiple organ failure, septic shock
The hysteroscopy is a real surgical intervention often performed in ambulatory without problems.
Whereas any operation involves risks of complications which can be linked to the anesthesia or to the procedure itself. Some complications can be serious or even fatal.
We report the case of a 60-year-old menopausal woman who died of septic shock after hysteroscopic surgery performed in the context of postmenopausal metrorrhagia.
Case ReportWe report the case of a 60-year-old woman, menopausal for 10 years, mother of two children, hypertensive on amlodipine, who consulted a gynecologist in private for postmenopausal bleeding.
An endovaginal ultrasound was performed, showing an intracavitary image of 15 mm in favor of a polyp. Then, the patient had an ambulatory hysteroscopy with polyp resection and endometrial biopsy.
Forty-eight hours later, the patient went to the medical-surgical emergency room for abdominal pelvic pain. The examination found a tachycardic, febrile, hypotensive patient with a saturation of 90% and diffuse abdominal sensibility.
A computed tomography (CT) scan of the abdomen and pelvis was performed to eliminate any perforation or pelvis peritonitis. During the realization of the CT scan, the patient started to desaturate with a fall of pressure to 90/50 mmHg.
The patient was admitted to the recovery room with conditioning and realization of biological sample (C-reactive protein 360), blood gases (lactate 4), then intubated on neurological criteria (Glasgow coma scale 12) and desaturation at 80%.
The CT result was in favor of an intra-uterine collection with hydroaeric level and an increased uterus size without any sign of perforation or pelvic peritonitis [Figure 1] and [Figure 2].
Figure 1: Sagittal section showing an increased uterus with intrauterine collection and hydroaeric level
Figure 2: Axial section showing an increased uterus with intrauterine collection and hydroaeric levelA gynecological examination was requested, and we performed an aspiration of the collection made of fetid blood with the realization of bacteriological samples and blood cultures.
Afterward, the patient was put under antibiotic therapy (imipinem with amikacine) and administration of the vasoactive drug (noradrenaline), but unfortunately, without any improvement, the patient died 3 h later.
The results of bacteriological sampling and blood culture were concordant and showed a sensitive Escherichia More Details coli.
DiscussionDiagnostic hysteroscopic procedures had very low complication rates,[1],[2],[3],[4] so they are safe procedures with which to evaluate intrauterine pathology. Operative hysteroscopic procedures were riskier, but the removal of polyps had a very low complication rate (12 times lower than synechiolysis).
Half the complications were entry-related; the most frequent surgical complication was perforation of the uterine cavity (rate of 0.76%). Approximately half the perforations were entry related.[5]
The risk of infection after surgical hysteroscopy is low (1.42%). In general, this concerns endometritis. Major infectious complications are rare.[6]
These rare complications can sometimes be very serious or even fatal, and Parkin reports the case of fatal toxic shock syndrome after endometrial resection in a 40-year-old woman. The case was reported to the Scottish National audit of hysteroscopic surgery.[7]
This case illustrates the importance of ascending infection even in generally safe procedures. Being alert for and enquiring about known risk factors (smoking, history of pelvic inflammatory disease, endometriosis, multiple partners, or recent change in sexual partner) can help reduce the incidence of post procedure infection. Currently, there is no evidence that antibiotic prophylaxis before transcervical procedures reduce infection rates, especially in diagnostic hysteroscopy.[8],[9]
Even though toxic shock syndrome presenting shortly after office hysteroscopy has been described, our patient had a late onset of septic shock.
We find in the literature[10] a case of a previously healthy 68-year-old woman who presented with abdominal pain and vomiting within 24 h of an outpatient hysteroscopy for postmenopausal bleeding. She was subsequently diagnosed with streptococcal toxic shock syndrome due to Group A beta-hemolytic Streptococci treated in the intensive care unit. She eventually recovered and was discharged home with oral antibiotics.[10]
Once the systemic infection is detected, prompt initiation of monitoring continuous electrocardiography and pulse oximetry is recommended.
Septic shock or multiple organ failure should be treated as a medical emergency requiring intensive care admission.
Resuscitation measures should be expeditiously undertaken: intravenous fluid infusion and large spectrum antibiotics, according to the institution's protocol. Blood and urine samples should be collected for culture aimed at identifying the pathogen.
In the presence of a large pelvic abscess, drainage is generally indicated; the choice of percutaneous or abdominal drainage, and Laparotomy or laparoscopic surgical route, will be dictated by technique availability and surgeon experience.
ConclusionTechnological advances in hysteroscopic surgical devices have brought this surgical modality to maturity in the 21st century. All operations carry a risk of complications, this risk is minimal for hysteroscopy, especially for diagnosis, but the occurrence of fatal complications leads us to respect the principles of safe surgery and asepsis rigorous.
Declaration of patient consent
The authors certify that they have obtained all appropriate patient consent forms. In the form, the patient's spouse has given his consent for her images and other clinical information to be reported in the journal. The patient's spouse understands that name and initials will not be published and due efforts will be made to conceal identity, but anonymity cannot be guaranteed.
Acknowledgment
The authors would like to thank all the doctors, nurses, and allied health-care professionals who were involved in the patient's care. Thanks also go to the Department of Gynecology-Obstetrics, Military Hospital of Instruction Mohamed V, Rabat, Morocco.
Financial support and sponsorship
Nil.
Conflicts of interest
There are no conflicts of interest.
References
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