Cervical Pregnancy Complicated With Group B Streptococcal Meningitis

By Sabadell, Jordi Sanchez-Iglesias, Jose Luis; Ferrer, Raquel; Higueras, Teresa; Et al

Abstract Maternal group B streptococcal infection is an uncommon entity. Herein we describe a case of a 27-year-old-woman who presented life-threateniing group B streptococcus meningitis with an ectopic cervical pregnancy. No other infectious focus have been found. To our knowledge this is the first time that this association has been reported.

Keywords: Group B streptococcus, Streptococcus agalactiae, meningitis, cervical pregnancy, ectopic gestation, metrorrhagia, uterine artery embolization

Case report

A 27-year-old woman presented at the emergency department with a three-day history of fever, headache and vomiting. She was known to be allergic to amoxicillin. Physical examination revealed a temperature of 40[degrees]C, a blood pressure of 90/50 mmHg, and a heart rate of 115 beats per minute. She had remarkable neck stiffness without cutaneous lesions or any other changes. The results of the rest of the physical examination were normal. During her stay at the emergency department she started to become confused and suffer speech difficulties.

Blood tests revealed a white cell count of 20 000 cells/mm^sup 3^ with left shift and no other abnormalities. Blood cultures were performed. Computed tomography of the head showed no abnormalities. Lumbar puncture was performed with a 23-gauge spinal needle at the L3-L4 level. Cerebrospinal fluid (CSF) examination revealed a clouded fluid with a high opening pressure, 8390 white blood cells with 94% of neutrophils, glucose less than 0.3 mmol/L, and protein levels of 5.64 g/L. Gram stain revealed Gram-positive cocci. Pneumococcal antigen in the CSF was negative.

Treatment with cefotaxime 2 g every 4 hours IV, dexamethasone 4 g every 8 hours, and phenytoin impregnation was started because of suspected streptococcal meningitis. Her consciousness level worsened despite early medical treatment; she was therefore moved to the intensive care unit for orotracheal intubation and mechanical ventilation. Twenty-four hours after admission, CSF and blood cultures grew Streptococcus agalactiae. Therefore, cefotaxime was replaced with ceftriaxone 2 g every 12 hours IV empirically; the patient was extubated 48 hours afterwards.

On the third day following admission, the woman started to have moderate vaginal bleeding with progressive anemia; a gynecological examination was required. At that moment the patient informed us that she had been diagnosed with a miscarriage one week previously, and because of this she had undergone ergotic treatment for four days. This whole process had started because of a three-week history of intermittent metrorrhagia. Gynecological examination showed moderate bleeding without any other abnormalities. beta-Human chorionic gonadotrophin (beta-hCG) plasma levels were 44 152 IU/L. Transvaginal ultrasonography showed a highly vascularized cervical mass suggestive of trophoblastic tissue.

Because ectopic pregnancy was suspected the patient was sent to our obstetric tertiary referral hospital. On arrival, she was afebrile, hemodynamically stable and conscious. Physical examination only revealed slight bleeding and cervical pain on bimanual exploration. A vaginal culture was performed. Repeat transvaginal ultrasonography showed an empty anteverted uterus with a decidualized endometrium of 9.9 mm, normal sized ovaries and no liquid in the cul-de-sac of Douglas. The cervical canal was enlarged due to an irregular and hypervascularized mass of 30 x 36 mm with no fetal node; this was suggestive of cervical ectopic pregnancy (Figure 1).

Expectant management for cervical pregnancy continued due to the clinical stability of the woman, the spontaneously decreasing beta- hCG plasma levels, and the contraindication for the use of methotrexate because of the active septic process.

During her admission, a chest X-ray, a transesophageal echocardiography, and an abdomino-pelvic computed tomography scan were performed, which revealed no abnormalities. The vaginal culture was positive for S. agalactiae, and this remained as the only starting focus for the septic episode.

Antibiotic treatment was continued for 21 days, and the patient improved. The vaginal bleeding ceased and beta-hCG titers decreased spontaneously to 4100 IU/L on the 16th day of her admission. Even so, the cervical image persisted, and for this reason a unique dosage of methotrexate 70 mg IM (50 mg/m^sup 2^) was administered. After that, beta-hCG levels decreased to 1576 IU/L.

Figure 1. (A) Transvaginal scan showing an empty uterine cavity with a dilated cervical canal (arrow) and closed internal os. (B) Color Doppler showing a hypervascularized endocervical mass owing to trophoblastic tissue.

On the sixth day after methotrexate administration the patient suddenly started to have lower abdominal pains accompanied by heavy vaginal bleeding that demanded a packed red blood cell transfusion. Given her hemodynamic instability the woman underwent uterine artery embolization and the metrorrhagia was controlled.

After embolization, beta-hCG plasma levels became negative, and the cervical image disappeared. The patient currently has regular menstrual cycles and no neurological sequelae.

Discussion

Ectopic gestations are estimated to occur in 2% of pregnancies and are responsible for 9% of pregnancy-related deaths. Their most frequent localization is tubal; cervical localization accounts for only 1% of ectopic pregnancies [1].

Cervical gestations have a high complication rate associated with massive bleeding and the loss of fertility. Group B streptococcal meningitis (GBSM) has not been related to cervical pregnancy before. Hence, several complementary tests were performed in order to rule out any other primary infectious focus. After that, cervical pregnancy remained the only focus for maternal sepsis.

Vaginal colonization by group B streptococcus (GBS, Streptococcus agalactiae) is common during pregnancy, and is related to several perinatal complications like: premature rupture of the amniotic membranes, chorioamnionitis, endometritis, prematurity, and neonatal sepsis. Maternal GBSM is very rare; in the literature it is always associated with invasive techniques and the postpartum period [2- 5].

GBSM is an important but uncommon manifestation of invasive GBS disease in adults; it may account for up to 4% of all cases of bacterial meningitis in this group. The incidence of invasive GBS infections among adults is higher in those with underlying conditions such as: diabetes, cirrhosis, cancer, and autoimmune diseases, and in puerperas and the elderly. Clinical manifestations include skin and soft tissue infections, septic arthritis, urinary tract infections, endocarditis, pneumonia, peritonitis, and meningitis [6-8]. The invasion of the cervical stroma by trophoblastic tissue could explain the passage of bacteria into the bloodstream deriving from endocervical colonization, and the ensuing infection of the central nervous system. S. agalactiae meningitis and sepsis should be considered to be a new potentially life- threatening complication of cervical pregnancy.

Nevertheless, the most usual and feared complication of a cervical pregnancy is massive bleeding, which can sometimes only be controlled with a hysterectomy. Currently, the elective treatment of cervical gestations is medical. The healing rate with systemic methotrexate, local injection of methotrexate or potassium chloride is over 80-90% [1,9-11]. Expectant management was an option that could be contemplated in the current case, due to the spontaneous progressive decrease in beta-hCG plasma levels, clinical stability with slight bleeding, and the relative contraindication for methotrexate therapy. The latter option would only be feasible with close surveillance, and if emergency rescue measures such as arterial embolization were available.

Surgical methods are being superseded by radiological interventionism. Selective uterine artery embolization has been reported as a technique that could, alone or combined with medical or surgical methods, be used to treat cervical pregnancies successfully [9,12-16]. Embolotherapy is also described as an effective method to control severe vaginal hemorrhage with a resolution rate close to 100% [12,15,16]. Such a therapeutic option seems to preserve women’s fertility and this case supports these findings [13,15].

References

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JORDI SABADELL1, JOSE LUIS SANCHEZ-IGLESIAS1, RAQUEL FERRER1, TERESA HIGUERAS1, JAUME ALIJOTAS2, & LUIS CABERO1

1 Department of Obstetrics and Gynaecology, Hospital Universitari Vall d’Hebron, Universitat Autonoma de Barcelona, Barcelona, Spain and 2 Department of Internal Medicine, Hospital Universitari Vall d’Hebron, Universitat Autonoma de Barcelona, Barcelona, Spain

(Received 11 January 2007; revised 19 January 2007; accepted 19 January 2007)

Correspondence: Jordi Sabadell, Department of Obstetrics and Gynaecology, Hospital Maternal Vall d’Hebron, Ps. Vall d’Hebron 119- 129, 08035 Barcelona, Spain. Tel: +34 93 4893066. Fax: +34 93 4894460. E-mail: jsabadga@yahoo.es

Copyright Taylor & Francis Ltd. May 2007

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