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A 24-year-old woman who delivered via C-section 8 days prior to admission presented with abdominal pain and signs of pulmonary embolism confirmed on CT-angiography. Of note, she had been treated for chorioamnionitis. The development of leucocytosis and fever, with recent abdominal surgery prompted imaging. CT abdomen/pelvis showed a multilocular fluid collection anterior to the uterus and abdominopelvic ascites. Piperacillin-tazobactam and linezolid were initiated, but she did not clinically improve; repeat imaging showed a posterior cul-de-sac fluid collection developing into an abscess (figure 1). The patient underwent drainage of both anterior and posterior collections, after which, initially, leukocytosis improved and the patient defervesced. However, due to relapsing fever and worsening leucocytosis, antibiotics were escalated to meropenem. The posterior fluid grew Escherichia coli and E. faecalis and anterior abscess cultures grew Mycoplasma hominis, which was not being covered. A literature search showed that M. hominis is a causative organism in postcaesarean abscesses, and moxifloxacin was successfully used as part of treatment. Therefore, it was decided to add coverage with moxifloxacin, which was proven susceptible on culture. Later on, repeat imaging showed new periaortic and perisplenic abscesses (figure 2), which, after drainage, resulted in significant clinical improvement. Only the periaortic abscess showed culture growth, which was M. hominis. She was prescribed a 6-week course of piperacillin-tazobactam for E. coli and E. faecalis coverage, and moxifloxacin for M. hominis coverage, which she completed outpatient. She received repeat CT abdomen/pelvis after completing antibiotics and it showed resolution of abscesses. Pelvic abscesses after endometritis occurs in less than 1% of postpartum women, with the most common areas being the broad ligament, posterior cul-de-sac and anterior to the uterine wall.1
From being so happy from the birth of my child to being fearful of losing my life and being hospitalised, this is my story: imagine you are feeling on top of the world with all the joy and happiness because you just had your first child. However, as soon as you are home, you start having pain to where you can not even sleep in your own bed. Two days later, your living room becomes your bedroom and it’s hard for you to breathe. Five days later, you would not even be able to walk to the bathroom or hold a breath.
Seven days after I delivered my child, I sat on the bathroom floor for over an hour unable to attend to my newborn child who was in the living room by himself. I knew I had to go to the hospital and eventually I was able to. Shortly after getting there, I could hardly move and when I had to get a CT scan, it took two people to move me every time. Following the CT scan, I learned that I had a blood clot in my lung along with some fluid. But that was not it, I had also developed abscesses in my stomach. By the time I got into a room around midnight, I was being told I had to move to the intensive care unit (ICU) because I was in critical condition at that point.
I arrived at the ICU where I stayed for over a week, not able to move and not able to see my child because of the pandemic. I never had any appetite, but I knew I had to fight to keep living. I forced myself to drink water, and eventually, I was able to eat some fruit about a week in.
By the second week, I had drains coming out of me while still needing oxygen. Doctors were able to remove the fluid from my lung and placed the drains for the first abbesses. My fever had gone away, and I felt like I was getting close to going home in a few days. But, then like magic they came back. Since I had started having fever again, I ended up getting another CT scan, which showed that there were more abscesses within my body, but this time, there was a dangerous area that if the doctors made a mistake, I could have a lot of bleeding and possibly die. After the second set of drains were put in, it took the doctors what felt like forever to make a final plan, but while they are planning, I was losing hope, finding myself filled with anger and being depressed. All I wanted to do during this time was to see my child and because I could not, it broke me down even more. Every day I had over 20 people come in my room and it felt like I heard something different each time. Eventually, all the drains came out but even then, the doctors wanted to keep me in the hospital for a few more days to be monitored. Finally, almost 3 weeks after being admitted, I was discharged home, but I still had to do intravenous therapy at home for another month to make sure the infections were cleared.
Because of my stay at the hospital, I went into a deep depression to where I did nothing but cry for hours every day for 2 weeks after I got home. It really messed with me mentally. I feel like all the things that happened to me in that one stay, would not happen to someone in their lifetime. I did improve and I finished my treatment. I got another scan, and it showed the abscess was gone but I still have to follow-up with doctors often. To this day, I still wonder why this happened to me and I am worried that this will happen again if I have another child.
Pelvic abscesses after endometritis most commonly occur in the broad ligament, posterior cul-de-sac and anterior to the uterine wall.
Due to its resistance to common antimicrobial drugs, it is important to bear mycoplasma in mind in the lack of clinical improvement, as it can prevent the potential spread and abscess formation in other organs.
Contributors SN and AH both equally contributed to the writing and ideas presented in the manuscript.
Funding The authors have not declared a specific grant for this research from any funding agency in the public, commercial or not-for-profit sectors.
Competing interests None declared.
Provenance and peer review Not commissioned; externally peer reviewed.