A 70-year-old woman with a history of uterine fibroids was looking for an emergency hospital with a chief complaint of dysarthria, when an acquaintance found her collapsed. She could barely speak when found, and upon arrival at emergency services by ambulance, she was in cardiopulmonary arrest. Her electrocardiogram waveform showed a pulseless electrical activity. She had not received bystander cardiopulmonary resuscitation (CPR), and ambulance crews started CPR upon arrival on the scene. After the administration of 1 mg adrenaline in the ambulance, the patient's heartbeat resumed. Thirteen minutes passed from the confirmation of cardiac arrest (at arrival at emergency services) to the ROSC. Her bilateral pupil diameter was 4 mm, but spontaneous breathing soon resumed.
On arrival, her vital signs were as follows: heart rate, 72 beats/min; blood pressure, 79/35 mmHg; and body temperature, 30.8 C. Assessment of her level of consciousness using the Glasgow Coma Scale revealed eye response of 1, verbal response of 1, and motor response of 1 (E1V1M1), but the bilateral pupil diameter had reduced to 3 mm. Blood gas analysis revealed pH of 6.909, PaCO2 of 80.8 mmHg, PaO2 of 67.9 mmHg, HCO3- level of 17.5 mmol/L, and lactate level of 7.0 mmol/L. On abdominal computed tomography (CT) (Figure 1), we observed ascites accumulation and fluid-containing uterine fibroids of approximately 10 cm in size.
 Figure 2 shows the patient's clinical course, and Figure 3 shows her laboratory data after admission. We could not identify the cause of cardiopulmonary arrest; thus, the nature of the ascites detected on CT was assessed. Puncture revealed the ascites to be purulent. We suspected septic shock due to an intraperitoneal infection and decided to perform emergency laparotomy, when a large volume of purulent ascites flowed out. Based on intra-abdominal findings, we speculated that some organs in the pelvis might have been infected, but we could not find the origin in the first-look surgery.
As a damage control strategy, we only performed open abdominal drainage and did not remove the uterus. For temporary abdominal closure, we used open abdomen management (OAM) using the VAC  system (KCI, San Antonio, TX, USA), with polymyxin B-immobilized fiber column direct hemoperfusion (PMX -DHP, Toray, Tokyo, Japan) immediately after surgery to stabilize the patient's circulatory dynamics.
Twelve hours after the patient's circulatory dynamics stabilized, we performed second-look surgery and again washed out the intra-abdominal cavity. On re-examining the uterus, we found a pore of approximately 1 cm at the top of the fibroid on the dorsal side and continuous discharge of pus. We judged the cause to be sepsis and immediately removed the uterus, with gauze packing to control oozing from the bottom of the pelvis. The small intestine was ischemic; hence, we again performed OAM for temporary abdominal closure (Figure 4).
We closed the abdomen on day 5 after the first damage control surgery. The patient's vital signs stabilized, and her inflammatory parameters improved and, finally, so did her level of consciousness.
Pathological findings (Figure 5) included a fibroma with abscess formation, peritonitis, adenomyosis, endometrial polyp, and endometrial stromal nodule of the uterine corpus. Examination of the uterus for pyometra revealed yellowish fragile areas with necrosis or abscess formation (Figures 5(a) and 5(b)). No malignancy was identified on histological examination (Figure 5(c)), suggesting a fibroma with inflammatory cell infiltration. Both blood and ascites cultures were positive for Peptostreptococcus micros, an anaerobic bacterium.
Soon after, the patient developed urinary tract infection due to right ureteral calculi, and extracorporeal shock wave lithotripsy was performed. On day 146, she was transferred to another hospital for rehabilitation for hypoxic encephalopathy.