A 40-year-old G5P3103 at 12 weeks and 3 days with a history of two prior cesarean sections and known heterotopic pregnancy consisting of cesarean scar pregnancy and intrauterine pregnancy (Figure 1) presented ten days after successful selective reduction of cesarean scar pregnancy with potassium chloride (KCl) injection in the ultrasonography unit.
The patient reported two days of fevers prior to her presentation with new onset vaginal bleeding. After her initial visit after selective reduction, she was treated with Nitrofurantoin for a urinary tract infection at urgent care. She presented two days after urgent care to our emergency department (ED) with pain and ultrasonographic evaluation that demonstrated no fetal heartbeat and discharge home for follow-up with her provider for management options. Three days after ED visit, she represented with new onset fevers, chills, back pain, and scant vaginal bleeding. She denied any significant past medical history and her previous surgical procedure included gastric bypass surgery, two cesarean sections, and an endometrial ablation for heavy menses.
On physical examination, the patient was febrile, tachycardic, hypotensive, and being in septic shock. She had scant dark blood in the vaginal vault, a 16 week size uterus with fundal tenderness. Ultrasound confirmed presence of no fetal cardiac activities and presence of high vascular flow to the myometrium surrounding the cesarean scar pregnancy (Figure 2).
The patient was counseled on septic abortion and she underwent a complete infectious disease workup, including blood cultures, urine cultures, and chest x-ray, and was started on broad-spectrum antibiotics (ampicillin, gentamicin, and clindamycin). Initial urine culture demonstrated no growth and initial blood culture grew Enterococcus faecalis. The patient desired uterine preservation and underwent bilateral uterine artery embolization using absorbable gelfoam and scheduled dilation and curettage under sonographic guidance the following day. The procedure was complicated with intraoperative hemorrhage of 1000cc that resolved with uterotonic medications and blood transfusion. Final pathology was consistent with products of conception. Hospitalized postoperatively, she continued to have daily low- grade fevers while on antibiotics with persistent daily positive blood cultures with Enterococcus faecalis. Antibiotic regimen was changed based upon the sensitivities to ampicillin and ceftriaxone, a normal echocardiogram ruled out endocarditis, and repeat transvaginal ultrasound demonstrated a large amount of heterogeneous avascular material in the lower uterine segment. The postoperative serum beta-hCG was 896 IU/L. CT scan of the abdomen and pelvis demonstrated a large high-density material within the endometrial cavity of lower uterine segment (Figure 3).
With concerns for persistent bacteremia, failed antibiotic therapy, and retained materials within the uterine cavity, the patient underwent a total abdominal hysterectomy and bilateral salpingectomy. The specimen was bivalved to show the entire uterine cavity with large amounts of blood clots, adherent placental tissue as well as a very thin anterior uterine segment (Figure 4).
Final pathology demonstrated products of conception with associated chronic and acute inflammation. Uterine culture obtained at hysterectomy demonstrated growth of Enterococcus faecalis, confirming the uterus as source of bacteremia. The patient had resolution of her fevers and negative blood cultures after the hysterectomy. Intravenous antibiotics were discontinued on postoperative day four and transitioned to a two-week course of Augmentin. She was discharged home with a two-week office follow-up. At her postoperative check and six-week visit she recovered fully.