A Rare Case Report of Tubo Ovarian Abscess with Mirena

Manjula Anagani1*, Mala Raj2 Prabha Agrawal1, B.Radhika1, A.Shalini1 and Dola.Sridevi1

1MaxCure suyosha Hospitals, Hitech city, Hyderabad
2Dip lap surgery(Germany), Dip Reproductive medicine(Germany), lap & infertility specialist, Firm Hospitals, Chennai, Tamilnadu, India

Corresponding author: MaxCure suyosha Hospitals, Hitech city, Hyderabad 2Dip lap surgery(Germany), Dip Reproductive medicine(Germany), lap & infertility specialist, Firm Hospitals, Chennai, Tamilnadu, India

Copyright: © 2016 Manjula Anagani, et al. This is an open-access article distributed under the terms of the Creative Commons Attribution License, which permits unrestricted use, distribution, and reproduction in any medium, provided the original author and source are credited.

Recevied Date: June 14, 2016, Accepected Date: June 28, 2016, Published: June 30, 2016

Citation: Manjula Anagani, Mala Raj Prabha Agrawal, B.Radhika, A.Shalini and Dola. Sridevi (2016) A Rare Case Report of Tubo Ovarian Abscess with Mirena. BAOJ Gynaec 1: 006.

Summary
We present a complicated case of a forty eight year female who came with complaints of lower abdominal pain with fever and vomiting since three days. She had history of menorrhagia since one year and had a Mirena intrauterine device placed for the same nine months back. On examination patient was febrile, vitals were stable, and abdomen was soft, uterus normal size with restricted mobility and tender cervical movements. Mirena was in situ. Ultrasound showed right tubo-ovarian mass of eight centimeters size. We believe that the tubo ovarian mass had developed secondary to the intrauterine device. With diagnosis of right tubo ovarian abscess with localized peritonitis she was planned for surgery. Antibiotic coverage was given. Total laparoscopic hysterectomy with left salpingectomy with right tubo ovarian mass excision with adhesiolysis was done. Pus culture was sterile. Postoperatively patient was stable and discharged on second day. Biopsy revealed chronic cervicitis with adenomyosis with acute suppurative salpingitis. We conclude that long-term IUD users remain at risk for serious, indolent pelvic infections and that clinicians should continuously address this issue with these patients during each encounter due to the fact that it hinders complete resolution of any new infection encountered.

Abstract:
Mirena is one of the commonest forms of IUD used worldwide because of its safety and efficacy. Some of the common side effects of Mirena are irregular periods and pelvic inflammatory disease with tubo-ovarian abscess being one of the rarer but sometimes a serious complication reported in less than 0.5% of users worldwide.

We report a rare presentation of tubo-ovarian abscess with Mirena. A P3L3A1, 48 year old female presented as an emergency to us with a 3 day history of lower abdominal pain, fever and vomitings. She had Mirena inserted nine months prior to presentation for management of menorrhagia. She was a known diabetic on oral medication. On presentation she was febrile, vitals were stable, abdomen was soft, uterus was normal in size with restricted mobility, cervical movements were tender and Mirena was in-situ. Ultrasound scan showed a right tubo-ovarian mass of 7.93x 4.33x 4.54 cm. A diagnosis of tubo-ovarian abscess with localized peritonitis was made . The patient underwent total laparoscopic hysterectomy, left Salpingectomy and excision of right tubo-ovarian mass with adhesiolysis. The patient had an excellent recovery and was discharged on the second postoperative day. The biopsy revealed chronic cervicitis with adenomyosis and acute suppurative salpingitis. The pus culture was negative.

Long term users of IUD’s remain at risk for serious pelvic infections due to the fact that it hinders complete resolution of any new infection encountered. Tubo-ovarian mass should be strongly considered in differential diagnosis of any IUD user who presents with adnexal mass, fever or abdominal pain. First-line of treatment should be medical. Surgery is reserved for cases failing to respond to medical therapy or who are at risk of rupture.

Introduction
A tubo-ovarian abscess is one of the less common forms of pelvic inflammatory disease found most commonly in women of reproductive age group and typically resulting from ascending upper genital tract infection. The reported incidence of pelvic inflammatory disease is 1.5% and that of tubo-ovarian abscess is less than 0.5%. Although there are case reports of tubo-ovarian abscess resulting from various intrauterine devices, there are very few case reports of abscess resulting from Mirena. We report a unique presentation of tubo-ovarian abscess resulting from Mirena, which we managed successfully with an excellent outcome.

Case Details
A 48 year old lady presented to us with complaints of lower abdominal pain, fever and vomiting of 3 days duration. She had history of menorrhagia for 1 year with 5/10-15 day cycle and Mirena insertion for the same. She was P3L3A1 with 3 previous vaginal deliveries and tubectomised 24 years back. She was a known diabetic on oral medication.

At the time of presentation the patient was afebrile, vitals were stable and there was no pallor, icterus or oedema. Systemic examination was normal. Abdomen was soft, and mildly tender. On per vaginal examination the uterus was normal in size with restricted mobility, cervical movements were tender and Mirena was in situ. The laboratory investigations revealed Hemoglobin of 10.3g/dl, Total leucocytes count of 11,000 cells/mm3, serum creatinine of 0.78 g/dl, random blood glucose 216mg/dl with negative virology screen. Liver and thyroid function tests were normal.

On Ultra sonogram uterus was bulky, 6.79x5.2x6.04 cm with endometrial thickness of 5.95cm and Mirena in lower half of uterine cavity. A right sided tubo-ovarian mass of 7.93x4.33x4.54cm was seen with free fluid in pod. Left ovary was normal.

A diagnosis of right tubo-ovarian abscess with localized peritonitis was made. Patient was admitted and treated with intravenous Cefoperazone-Sulbactam and Metronidazole and then taken up for laparoscopy. The abdomen was entered with three 5mm ports and pneumoperitoneum was created. There were mental adhesions to anterior abdominal wall, bowel adhesions to posterior surface of uterus and bladder adhesions to fund us of uterus. The adhesions were released and anatomy was restored. The uterus was bulky, the left tube was congested and the ovary was normal. There was a right tubo-ovarian mass adherent to posterior surface of uterus with pus collection. The adhesions were released; pus sample collected and sent for culture and sensitivity. A total laparoscopic hysterectomy with left salpingectomy, right tubo-ovarian mass excision with adhesiolysis was done. Peritoneal lavage was done, haemostasis secured, bladder integrity checked, vault closed with vicryl , wound packed with surgicele, drain kept in situ. A specimen was sent for histopathology which showed chronic cervicitis with adenomyosis with acute suppurative salpingitis. The pus culture did not grow any organisms.

The patient had an uneventful post-operative recovery and was discharged on the 2nd post operative day.
Discussion
Pelvic Inflammatory Disease is an established issue with the use of any IUD. Historically, the use of certain intrauterine devices was associated with increased risk of pelvic inflammatory disease. More recent evidence suggests that newer devices do not carry the same threat; however, certain risk factors can increase the possibility of infection [1].

The usual causes of pelvic sepsis are previous history of pelvic inflammatory disease, multiple sexual partners, intrauterine manipulation and intrauterine devices. Although Mirena is known to cause the least among all IUD’s, pelvic infection is common in the first few days to weeks after insertion. The reasons are manifold. Infection could originate from insertion, flaring of an old undiagnosed infection, sexually acquired infections (STI) and from the inflammation caused by the IUD which weakens local immunity to microorganisms. It is noteworthy that Mirena IUD does not protect against sexually transmitted infections. Instead a barrier contraceptive is needed to avoid contracting an STI while using Mirena along with regular STI screening services.

The importance of pelvic sepsis lies not only with the morbidity associated with acute stages of the disease but also with the serious nature of the chronic sequelae which may result. Tubo-ovarian abscess is a consequence of untreated or ineffectively treated pelvic sepsis, and the first-line of treatment should be medical. Surgery is reserved for cases failing to respond to medical therapy or where rupture is thought likely. If surgery is appropriate, conservative measures will maintain the patient’s reproductive potential while removing the primary focus of infection. In older patients who have completed their families, radical surgery may be appropriate. Treatment modalities include broad spectrum antibiotic therapy, minimally-invasive drainage procedures, invasive surgery, or combinations of these interventions. Rupture of a tubo-ovarian abscess is rare now, due to earlier initiation of effective antibiotic treatment of pelvic sepsis. However, if access to medical facilities has been delayed, rupture is potentially a most serious complication, which is associated with high mortality. On the assumption that all pelvic organs harbour infective microfoci, hysterectomy and bilateral salpingo-oophorectomy was, until recently, the standard surgical procedure for tubo-ovarian abscesses. Undoubtedly, this radical approach offers the best chance of a definitive cure, and in older patients who have completed their families it may still be the most appropriate. The consequence of surgical menopause can be overcome using hormone replacement therapy, and as there is no longer any risk of endometrial malignancy, unopposed oestrogens can be administered.

In a fact med study of possible correlation between tubo-ovarian abscess and mirena it was found that out of any side effects of MIRENA in 63,046 patients the number of MIRENA causing tubo-ovarian abscess was 37. The percentage of MIRENA patients where tubo-ovarian abscess is a reported side effect was 0.0587% [2]. In a study by eHealthMe 61,256 people reported to have side effects when taking Mirena .Among them, 36 people (0.06%) had Tubo-ovarian Abscess [3].

There is some evidence that TOA size is associated with need for intervention. Reed et al. in 1991 showed that 35% of abscesses 7 to 9 cm required surgery and nearly 60% of abscesses =10 cm required surgery. It showed a 35% failure rate for abscesses between 7 and 9 cm and a 60% failure rate for abscesses =10 cm with medical management [4]. A retrospective study by DeWitt et al. found that TOAs with a maximum diameter greater than 8 cm were associated with a higher risk of complications, including increased need for drainage or surgery when compared to smaller abscesses (35% versus 9%, resp). The study showed a 43% failure rate when only medical management was used for abscesses >8 cm (5).

Conclusion
The IUD is known to disrupt the normal protective mechanism of the endometrial cavity which may continually promote the possibility of infection. The Mirena coil system is designed to minimize the risk of infection, but there is still a slight risk of developing a pelvic infection while using the coil, particularly in the first 3 weeks after insertion. Overall, about 1.5% of women will develop an infection with 5 years use of Mirena. We conclude that long-term IUD users remain at risk for serious, indolent pelvic infections and that clinicians should continuously address this issue with these patients during each encounter due to the fact that it hinders complete resolution of any new infection encountered. A tubo-ovarian abscess should be considered high in the differential diagnosis in any IUD user who presents with a tubo-ovarian complex, fever, or abdominal pain. The device should be removed when prodromal symptoms arise and the patient should be treated with antibiotics. Should a tubo-ovarian abscess develop, surgical intervention is necessary.

References
Best Practices to Minimize Risk of Infection with Intrauterine ... - SOGC

factmed.com/study-MIRENA-causing-TUBO-OVARIAN%20ABSCESS.php

SD Reed, DV Landers, RL Sweet (1991) “Antibiotic treatment of tuboovarian abscess: comparison of broad-spectrum ß-lactam agents versus clindamycin-containing regimens.” AJOG, 164(6): 1556-1561.

J DeWitt A, Reining JE., Allsworth, JF Peipert (2010) “Tuboovarian abscesses: is size associated with duration of hospitalization & complications?.” Obstetrics and Gynecology International Article ID 847041.