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The rare case of a pelvic abscess following caesarean section in a Sri Lankan woman: an argument for medical student electives

Abstract

Introduction: A pelvic abscess is a rare complication that can occur following gynaecological and obstetric procedures. Whilst the condition is not confined geographically, women in less developed countries are at an increased risk of developing this complication, due in part to low resource settings, socioeconomic status, and educational attainment.

Case: A 36 year old primigravid woman in rural Sri Lanka undergoing a non-emergency caesarean section delivery developed clinical signs of puerperal sepsis two days postpartum. Following transfer to a tertiary hospital, imaging and laparotomy confirmed the presence of a pelvic abscess associated with the caesarean section wound. Surgical drainage was performed and IV antibiotics were administered, ultimately resulting in the full recovery of the patient. The infant did not demonstrate clinical signs of sepsis at birth.

Discussion: Numerous factors contributed to the development of this serious complication in this patient, including increased maternal age at first pregnancy, caesarean section management, and the low resource setting of the patient’s care. This case also highlights the difficulties and barriers facing patients and doctors in less developed countries, including that of patient transfers from a rural setting and the availability of specific antibiotics recommended in clinical guidelines. The barriers to optimal care faced by this woman are largely disconnected from the experiences of patients that Australian medical students see in their day-to-day training. Overseas electives to low resource areas should be required and supported amongst all Australian medical students to facilitate greater appreciation for such barriers and to foster their skills in resourcefulness and empathy.

 

Introduction

As a demonstration of the public health issues and associated complications that arise in less developed countries, the following presents a rare case of pelvic abscess formation following caesarean section delivery. This is written from the perspective of an Australian medical student on an obstetrics and gynaecology elective in rural Sri Lanka.

Pelvic abscess is considered a rare complication of pelvic surgery, affecting less than 1% of women undergoing any obstetric or gynaecological procedure [1]. The implications of such a complication are more significant when they occur in a low resource setting, such as Sri Lanka [2]. Data suggest puerperal sepsis accounts for 11.6% of maternal mortality in such settings, compared with 2.1% in developed countries [3]. A range of factors contribute to the risk of puerperal sepsis and pelvic abscess, including increasing maternal age at first pregnancy, high caeserean section rates, and low socioeconomic and educational status, all well-documented factors present in this patient and their demographic [2,4,5]. Whilst pelvic abscess is a complication that has no geographical boundaries, women in less developed countries are at increased risk of dying from this complication [3]. This is likely compounded by sub-optimal infection control and limited access to resources, including trained midwifery and obstetric care [2]. This is reflected in the high rate of hospital-acquired infections, up to 50%, resulting from surgical site wounds [3]. Despite the high morbidity and mortality of pelvic abscesses and puerperal sepsis, the actual incidence of both conditions is poorly defined [3]. The following case exemplifies some of these challenges.

 

Case

A 36 year old primigravid woman underwent a caesarean section with no immediate surgical complications, in the setting of a reportedly uneventful pregnancy. Surgery was performed at a local rural hospital in Sri Lanka, approximately three to four hours by road transfer from the capital, Colombo. The reason for caesarean section was unclear; however, it was understood that the caesarean section was performed in a non-emergency setting. Two days postpartum, the woman developed fever (temperature not specified) and complained of a triad of foul-smelling and purulent lochia, abdominal distension, and dyspnoea, according to the patient and her family. The patient was denied transfer by the treating hospital, and so the family arranged private transportation to a tertiary centre in Colombo. She arrived in a state of septic shock: mildly hypothermic (36.0˚C), tachypnoeic (45 breaths/min), hypertensive (150/100 mmHg), tachycardic (150 beats/min), and cyanotic with significant generalised oedema. Computerised tomography of the abdomen and pelvis identified abscess formation anterior to the uterine sutures and significant fluid in the peritoneal cavity. An emergency laparotomy was performed. A dehiscence of her uterine scar was repaired and two litres of pus was drained. The fluid cultured positive for Group B beta-haemolytic Streptococcus, sensitive to vancomycin. The patient was subsequently commenced on intravenous antibiotics (vancomycin, metronidazole, and meropenem) post-operatively.

Following surgery, hyperglycaemia (180-250 mg/dL) and hypertension (160/110 mmHg) persisted for some weeks, with recovery complicated by a secondary wound infection requiring additional antibiotics (flucloxacillin and metronidazole) and a second laparotomy. Mother and baby ultimately recovered completely, with no clinical signs of postnatal sepsis reported in the child. Clinical guidelines for puerperal sepsis recommend a combination of broad-spectrum antibiotics, targeting the common polymicrobial sources, including anaerobic organisms (E. coli and S. pyogenes), and surgical abscess drainage [5,6]. This case failed to utilise the recommended first-line empirical antibiotics. Poor antibiotic practices, unreliable antibiotic supplies, and a lack of adequate medication delivery protocols are cited as common reasons for increasing rates of puerperal sepsis in the developing world, with one or more of these factors potentially influencing antibiotic choice in this case [2,4].

 

Discussion

Although the woman had a full recovery, this case serves as a reminder of the seriousness of obstetric complications, and how they may be compounded by geographical factors and a paucity of adequate medical resources. This case offered significant opportunity for learning and personal reflection. Primarily, I was able to recognise that the outcomes of childbirth and postnatal care in less developed countries may be vastly different to such events occurring in Australia. Some of the difficulties I observed included inadequate systems for medical documentation, and communication of results and information for clinical handover. The disparity in access to such basic resources is alarming, and I believe all medical professionals should be angry about such injustices. To fully understand this degree of inequality, however, it required the immersive experience of an elective term in Sri Lanka. Based on my own experience, I would strongly recommend an overseas elective as a mandatory component of any Australian medical degree. This could be a useful step in helping Australian graduates to become more resourceful. In addition, it will help our graduates recognise the importance of an effective and well-resourced, high-quality health system in achieving the best health outcomes for our patients.

 

Consent declaration
Informed consent was obtained from the patient for publication of this case report.

Acknowledgements
Dr Roshan Zaid (consultant obstetrician and gynaecologist, Nawaloka Hospital, Colombo, Sri Lanka), a senior consultant involved in the above patient’s care, who provided clinical advice and support in compiling this report.

Financial assistance for this elective was provided in the form of a bursary from the University of Melbourne.

Conflict of interest
None declared.

 

References

  1. Mahdi H, Goodrich S, Lockhart D, DeBernardo R, Moslemi-Kebria M. Predictors of surgical site infection in women undergoing hysterectomy for benign gynecologic disease: a multicenter analysis using the national surgical quality improvement data. J Minim Invasive Gynecol. 2014;21(5):901-9.
  2. Buddeberg BS, Aveling W. Puerperal sepsis in the 21st century: progress, new challenges and the situation worldwide. Postgrad Med J. 2015;91(1080):572-8
  3. Hussein J, Walker L. Puerperal sepsis in low- and middle-income settings: past, present and future. In: Kehoe S, Neilson J, Norman J, editors. Maternal and infant deaths – chasing millennium development goals 4 and 5. Cambridge: Cambridge University Press; 2010.
  4. Knowles S, O’sullivan N, Meenan A, Hanniffy R, Robson M. Maternal sepsis incidence, aetiology and outcome for mother and fetus: a prospective study. BJOG. 2015;122(5):663-71.
  5. The World Health Organisation. Managing puerperal sepsis – midwifery education module 4: avoidable factors. 2nd ed. Geneva: The WHO Press; 2008.
  6. The Royal College of Obstetrics and Gynaecology. Bacterial sepsis following pregnancy. Green-top Guideline No. 64B [Internet]. 2012 [cited 2016 Nov]. Available from: https://www.rcog.org.uk/en/guidelines-research-services/guidelines/gtg64b/