Int J Gynaecol Obstet 15: 464-465, 1978
Septic Abortion and Acute Renal Failure in a Patient with an Intrauterine Contraceptive Device C. M. Wiles, S. L. Cohen, and R. H. T. Ward University
College Hospital,
London,
England
INTRODUCTION Recent attention has been drawn to the relationship between maternal death and the use of an intrauterine contraceptive device (IUD) (1, 3). Our report presents the case history of a patient who suffered a septic abortion that was probably caused by an IUD.
CASE REPORT A 20-year-old married woman, gravida 2, was first seen at our antenatal clinic at approximately 18 weeks' gestation. A previous pregnancy, 3 years earlier, had been terminated at 11 weeks' gestation. Subsequently, the patient had a Copper-7 IUD fitted and checked regularly. As a child, the patient suffered from gross bladder instability and repeated episodes of urinary tract infection and incontinence. At the age of eight, a urinary diversion had been established, utilizing a sigmoid colonic conduit. Recurrent pyelonephritis necessitated a right nephrectomy when the patient was 11. The patient's blood urea nitrogen (BUN) and creatinine levels were normal at the time of her clinic visit. She was admitted to the hospital at 25 weeks' gestation with premature rupture of the membranes. The following day the patient was febrile, and fetal heart sounds were absent. Bactériologie specimens were taken, and the patient was treated immediately with penicillin, gentamicin and lincomycin. Later in the day, the fetus was delivered following an infusion of Syntocinon® (Sandoz Pharmaceuticals, East Hanover, N. J., USA). A foulsmelling discharge accompanied delivery. Manual removal of the placenta and the IUD was necessary under anesthetic. Twenty-four hours after delivery, the patient became hypotensive (blood pressure, 50/30 mm Hg) and oliguric (50 ml in 12 hours) and had paralytic ileus. Her jugular venous pressure was not elevated,
Int J Gynaecol
Obstet
15
her peripheries were warm, and there was no evidence of hemorrhage. A prehminary diagnosis of gram-negative shock was made and later confirmed by the cultivation of Escherichia coli from blood samples and endocervical swabs. After correcting the patient's central venous pressure (CVP), her blood pressure (BP) rose transiently to 80/60 mm Hg. A single dose (30 mg/kg) of methylprednisolone was given intravenously, and her BP subsequently was maintained. Despite these measures, oliguria persisted. By her fifth postoperative day, the patient's plasma creatinine level had risen to 1 414 ¿/mole/liter (16 mg/dl) and her BUN to 45.9 mmole/liter (257 mg/dl). The patient's fluid intake was restricted, and she was provided with a high-calorie diet via a CVP line because of her paralytic ileus. Diuresis commenced after 4 days, and the patient's plasma creatinine level fell to 168 ¿¿mole/liter (1.9 mg/dl). The patient was advised on alternative contraceptive measures and was started on a combined oral contraceptive prior to discharge from the hospital.
COMMENT The recent report of Cates et al. (1) suggests that the maternal mortality rate in spontaneous abortion is increased substantially in those women using an IUD. Such deaths frequently have been associated with sepsis (2, 4). However, Williams et al. (5) found four cases of septic abortion without serious maternal illness in 58 spontaneous abortions occurring in association with an IUD. The patient described in this report had a gramnegative septicemia complicated by acute renal failure following premature rupture of the membranes with a Copper-7 IUD in situ. Her renal reserve was already reduced by previous nephrectomy. This case emphasizes that septic abortion represents one of the risks confronting women using an IUD.
Septic abortion and renal failure with IUD
REFERENCES 1. Cates, W, Jr, Ory, H W, Rochat, R W & Tyler, C W, Jr: The intrauterine device and deaths from spontaneous abortion. N Engl J Med 295.1155, 1976. 2. Christian, C D: Maternal deaths associated with an intrauterine device. Am J Obstet Gynecol 779:441, 1974. 3. Maternal death and the I U D . Lancet 2:1234, 1976. 4. Thomas, A K: Septic abortion associated with a Lippes loop. Br Med J 3:747, 1975. 5. Williams, P, Johnson, S & Vessey, M: Septic abortion in women using intrauterine devices. Br Med J 4:263, 1975.
465
Address for reprints: Humphry Ward Department of Obstetrics and Gynaecology University College Hospital Medical School Huntley Street London, WC1E 6DH England
Int J Gynaecol
Obstet
75
Septic Abortion and Acute Renal Failure in a Patient with an Intrauterine Contraceptive Device C. M. Wiles, S. L. Cohen, and R. H. T. Ward University
College Hospital,
London,
England
INTRODUCTION Recent attention has been drawn to the relationship between maternal death and the use of an intrauterine contraceptive device (IUD) (1, 3). Our report presents the case history of a patient who suffered a septic abortion that was probably caused by an IUD.
CASE REPORT A 20-year-old married woman, gravida 2, was first seen at our antenatal clinic at approximately 18 weeks' gestation. A previous pregnancy, 3 years earlier, had been terminated at 11 weeks' gestation. Subsequently, the patient had a Copper-7 IUD fitted and checked regularly. As a child, the patient suffered from gross bladder instability and repeated episodes of urinary tract infection and incontinence. At the age of eight, a urinary diversion had been established, utilizing a sigmoid colonic conduit. Recurrent pyelonephritis necessitated a right nephrectomy when the patient was 11. The patient's blood urea nitrogen (BUN) and creatinine levels were normal at the time of her clinic visit. She was admitted to the hospital at 25 weeks' gestation with premature rupture of the membranes. The following day the patient was febrile, and fetal heart sounds were absent. Bactériologie specimens were taken, and the patient was treated immediately with penicillin, gentamicin and lincomycin. Later in the day, the fetus was delivered following an infusion of Syntocinon® (Sandoz Pharmaceuticals, East Hanover, N. J., USA). A foulsmelling discharge accompanied delivery. Manual removal of the placenta and the IUD was necessary under anesthetic. Twenty-four hours after delivery, the patient became hypotensive (blood pressure, 50/30 mm Hg) and oliguric (50 ml in 12 hours) and had paralytic ileus. Her jugular venous pressure was not elevated,
Int J Gynaecol
Obstet
15
her peripheries were warm, and there was no evidence of hemorrhage. A prehminary diagnosis of gram-negative shock was made and later confirmed by the cultivation of Escherichia coli from blood samples and endocervical swabs. After correcting the patient's central venous pressure (CVP), her blood pressure (BP) rose transiently to 80/60 mm Hg. A single dose (30 mg/kg) of methylprednisolone was given intravenously, and her BP subsequently was maintained. Despite these measures, oliguria persisted. By her fifth postoperative day, the patient's plasma creatinine level had risen to 1 414 ¿/mole/liter (16 mg/dl) and her BUN to 45.9 mmole/liter (257 mg/dl). The patient's fluid intake was restricted, and she was provided with a high-calorie diet via a CVP line because of her paralytic ileus. Diuresis commenced after 4 days, and the patient's plasma creatinine level fell to 168 ¿¿mole/liter (1.9 mg/dl). The patient was advised on alternative contraceptive measures and was started on a combined oral contraceptive prior to discharge from the hospital.
COMMENT The recent report of Cates et al. (1) suggests that the maternal mortality rate in spontaneous abortion is increased substantially in those women using an IUD. Such deaths frequently have been associated with sepsis (2, 4). However, Williams et al. (5) found four cases of septic abortion without serious maternal illness in 58 spontaneous abortions occurring in association with an IUD. The patient described in this report had a gramnegative septicemia complicated by acute renal failure following premature rupture of the membranes with a Copper-7 IUD in situ. Her renal reserve was already reduced by previous nephrectomy. This case emphasizes that septic abortion represents one of the risks confronting women using an IUD.
Septic abortion and renal failure with IUD
REFERENCES 1. Cates, W, Jr, Ory, H W, Rochat, R W & Tyler, C W, Jr: The intrauterine device and deaths from spontaneous abortion. N Engl J Med 295.1155, 1976. 2. Christian, C D: Maternal deaths associated with an intrauterine device. Am J Obstet Gynecol 779:441, 1974. 3. Maternal death and the I U D . Lancet 2:1234, 1976. 4. Thomas, A K: Septic abortion associated with a Lippes loop. Br Med J 3:747, 1975. 5. Williams, P, Johnson, S & Vessey, M: Septic abortion in women using intrauterine devices. Br Med J 4:263, 1975.
465
Address for reprints: Humphry Ward Department of Obstetrics and Gynaecology University College Hospital Medical School Huntley Street London, WC1E 6DH England
Int J Gynaecol
Obstet
75
