Postpartum Pyomyoma, a Rare Complication of Sepsis Associated with Chorioamnionitis and Massive Postpartum Haemorrhage Treated with an Intrauterine Balloon

Abstract

We report the successful treatment of a postpartum pyomyoma, a rare but serious complication of uterine leiomyomata in a 28-year-old primigravida. The patient was treated for an Escherichia Coli (E. Coli) urinary tract infection (UTI) at 16 weeks of gestation. She had asymptomatic short cervical length on ultrasound scan at 20 weeks that was managed conservatively due to the presence of further UTI and received antibiotics. She was known to have a left sided intramural leiomyoma. She presented with abdominal pain and vaginal bleeding at 23+1 weeks of gestation and the next day she had spontaneous vaginal delivery and collapsed with E. Coli septic shock, massive postpartum haemorrhage, and disseminated intravascular coagulation and was successfully treated with oxytocic drugs, a Rusch intrauterine balloon, and intravenous antibiotics. Eleven days postnatally she re-presented with systemic sepsis and was treated for retained products of conception. Sepsis persisted and investigations showed a postpartum pyomyoma that was initially managed with intravenous antibiotics to avoid surgery. Ultimately she required laparotomy, drainage of pyomyoma, and myomectomy. Postoperative recovery was good and the patient had a successful pregnancy two years later.

Prolapsed submucosal pyomyoma postpartum, a rare complication of fibroids

“…The transmission route postpartum is usually ascending infection, which will lead to the colonization of necrotic tissue. However, it can also spread from the uterine cavity or any adjacent structures or by distant hematogenous/lymphatic spread [4,[11][12][13][14].…”

Spontaneous Ruptured Pyomyoma in a Nulligravid Female: A Case Report and Review of the Literature

“…The outcome of one of the patients was not reported. Since 2010, 10 of 25 cases were treated with hysterectomy (40%) [ 1 – 3 , 5 , 6 , 8 – 19 , 21 – 26 ], and only 2 of 11 patients under age 40 (18%) were treated with hysterectomy, so there may be a trend toward managing cases with conservative surgical treatments for fertility preservation purposes. The majority of cases were in premenopausal women or were associated with pregnancy, uterine artery embolization, or uterine instrumentation (e.g., IUD in place, D&E).…”

“…Cases in the immediate postpartum period or after uterine instrumentation, e.g., after a D&C, are thought to be most likely the result of ascending infection [ 1 ]. Use of instrumentation in the case of postpartum hemorrhage, including intrauterine balloons, also increases risk of infection, while hemorrhage increases risk of infarction of fibroids [ 8 ]. Recently, uterine artery embolization (UAE) has become more popular as a treatment for fibroids, as it offers an alternative to traditional surgical and medical therapies [ 3 , 9 ].…”

“…MRI has not been shown to be helpful in diagnosis. The differential diagnosis includes pyometra, tuboovarian abscess, an infected ectopic pregnancy, malignancy, perforated viscus, or degenerating fibroids [ 2 , 8 ]. The most feared complication of a pyomyoma is rupture, followed by sepsis and death [ 9 ].…”

“…Rupture is suggested on imaging by disruption of the wall of the pyomyoma, along with free intraperitoneal fluid and air [ 1 ]. Mortality rate estimates range from 6% to 21% in the era of antibiotics [ 5 , 8 , 14 , 16 ]. Prior to the development of antibiotics in 1945, the mortality rate was 29% according to case series [ 17 ].…”