July 4, 2007
Life-Threatening Septic Shock in a Pregnant Woman With Ileus
By Hiromura, Katsuhiko Furuhashi, Madoka; Minami, Kojiro; Miyazaki, Ken; Et al
Abstract Septic shock during pregnancy is very rare but has high mortality. We report a case of septic shock in a pregnant woman with ileus, showing that severe ileus in a pregnant woman could be attributed to life-threatening septic shock and that we should give special attention to a nosocomial infection.
Keywords: Septic shock, ileus, pregnancy, Klebsiella pneumoniae, Stenotrophomonas maltophilia
Septic shock during pregnancy is very rare but has high mortality . Although fatal toxic syndrome associated with Clostridium sordellii after medical abortion has recently become an issue of growing concern in the field of obstetrics , septic shock in a pregnant woman with ileus has not been reported in the English literature.
A 32-year-old primigravida with previous laparotomy and lysis of adhesions due to endometriosis was admitted at 25 weeks and 6 days of gestation with nausea, vomiting, and abdominal pain. Her temperature and blood pressure on admission were 36.7[degrees]C and 108/74 mmHg, respectively. Fetal heart rate monitoring showed a reassuring status of the fetus. Abdominal X-ray demonstrated distension of fluid- and gas-filled loops of small intestine with airfluid levels, leading to a diagnosis of ileus. Fasting and intravenous hyper-alimentation were initiated, and a long intestinal tube was passed into the small intestine, providing symptomatic relief. She suddenly developed a fever of 39.5[degrees]C and complained of abdominal pain and vomiting again at 27 weeks and 6 days of gestation (day 0 of sepsis). The fetal heart sound was inaudible on the following day (day 1) and intrauterine fetal demise was confirmed by ultrasonography. Pertinent laboratory results were as follows: white blood cell count 24400/mm^sup 3^, hemoglobin 11.6 g/dL, hematocrit 33.0%, platelet count 50 000/mm^sup 3^, C-reactive protein 15.4 mg/dL, blood urea nitrogen 33 mg/dL, creatinine 1.9 mg/ dL, sodium 133 mmol/L, potassium 3.2 mmol/L, aspartate aminotransferase (AST) 47 IU/L, alanine aminotransferase (ALT) 45 IU/ L, fibrin degradation product (FDP) 112[mu]g/mL, endotoxin 42 pg/ mL. She was noted to have good color, petechia, blood pressure of 70- 80/40-50 mmHg, and a pulse rate of 140 beats per minute (bpm). She delivered the stillborn baby of 1225 g by vacuum extraction, followed by transfer to the intensive care unit. A blood culture obtained before antibacterial therapy later revealed Gram-negative rods identified as Klebsiella pneumoniae. A culture obtained from the vagina was found to be negative for bacteria. There was no evidence of urinary tract infection. Placental pathology did not demonstrate any evidence of chorioamnionitis and funisitis. The patient was diagnosed as having septic shock and consequential disseminated intravascular coagulation (DIC).
Continuous hemodiafiltration (CHDF) was started, and direct hemoperfusion with polymyxin B-immobilized fiber was performed two times over the following day to eliminate cytokines and endotoxin. Blood transfusions were undertaken with fresh frozen plasma, packed thrombocytes, and packed red cells. Positive inotropic therapy with dopamine was given. For DIG and CHDF, nafamostat mesilate and/or gabexate mesilate were used. In addition to immunoglobulin, antibiotics were used in combination with meropenem and minocycline, followed by cefepime dihydrochloride plus minocycline. After four days of aggressive management, the patient's fever subsided and she got through the crisis, although she still needed oxygen support and dopamine. On day 7, she had a fever of 39.7[degrees]C again. Her chest X-ray film showed an infiltrative shadow in the left lower lobe and left pleural effusion. Sputum culture later exhibited Stenotrophomonas maltophilia. Many different types of antibiotics in different combinations were used, which included minocycline, ciprofloxacin sodium, latamoxef sodium plus amikacin sulfate, and latamoxef sodium plus sulfamethoxazole/trimethoprim. She resisted the treatment and it took more than 14 days for her temperature to return to normal. On day 12, she started oral ingestion because no evidence of ileus was observed. Sputum culture was positive for Stenotrophomonas maltophilia on day 15, but it became sterile on day 21. She left the hospital on day 32.
Ileus during pregnancy is a rare complication. However, several factors lead us to predict its increase in the near future: (1) The number of laparotomy procedures performed in women of reproductive age has been increasing. For example, the frequency of cesarean delivery has substantially increased . Also, myomectomy is an option recommended to women with infertility and women predisposed to repeated pregnancy loss because of myomas . Adhesions are formed after peritoneal surgery and intra-abdominal adhesions can cause bowel obstruction . Actually, ileus as a surgical complication has been reported to increase with the number of cesarean deliveries . (2) Due to the advance in assisted reproductive technology and surgery including laparoscopy, even patients with severe anatomical distortion of the pelvis caused by endometriosis or pelvic infection have been given more opportunity to achieve pregnancy.
We have come across six pregnant women with ileus who needed intravenous hyper-alimentation and long intestinal tubes, including the above case, over the last 10 years. All of them required some interventions to provide further symptomatic relief. Three women were cured only through vaginal delivery or delivery by cesarean section. Three women needed surgical relief of adhesions or excision of a lesion with restoration of intestinal continuity: one during pregnancy, one at cesarean section, and one after cesarean section. These cases showed us that operations should not be abandoned despite improvement in the well being of patients during conservative treatment. Obstetricians should keep in mind that pathophysiology of the ileus in pregnant women is different from that in nonpregnant women mainly due to mechanical compression by an enlarged uterus.
The etiology of septic shock in the presenting case is unknown. An intriguing hypothesis is sepsis of gut origin. In addition to animal studies, several reports have supported the hypothesis that gut translocation of bacteria acts as a source of sepsis in humans [7,8]. Gut bacterial translocation occurs especially in patients with intestinal obstruction . Furthermore, a recent study has shown that total parenteral nutrition (TPN) is associated with an increased prevalence of gut bacterial translocation , although it is still a matter of argument. Considering that (1) there was no possible site of infection, (2) the primary causative organism was Klebsiella pneumoniae, which is found in the normal flora of the intestines, (3) the patient had ileus, and (4) the patient received TPN, gut origin is inferred.
Another issue in the presenting case is the pneumonia caused by Stenotrophomonas maltophilia, which shows resistance to most antimicrobial agents [11,12]. Stenotrophomonas maltophilia is increasingly recognized as an opportunistic pathogen in debilitated hosts. Because a significant association with carbapenem use has been reported [13,14], the choice of antibiotics for primary infection should be taken with care.
In conclusion, severe ileus in a pregnant woman could be attributed to life-threatening septic shock. When the fetus is expected to be able to survive outside the uterus, earlier delivery should be considered. Also, we should give special attention to a nosocomial infection especially one caused by antibiotic-resistant bacteria.
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KATSUHIKO HIROMURA, MADOKA FURUHASHI3 KOJIRO MINAMI, KEN MIYAZAKI, KANA YOSHIDA, NAOHIKO KUNO, & KAORU ISHIKAWA
Department of Obstetrics and Gynecology, Japanese Red Cross Nagoya First Hospital, Nagoya, Japan
(Received 23 November 2006; revised 12 January 2007; accepted 12 January 2007)
Correspondence: Dr Madoka Furuhashi, Department of Obstetrics and Gynecology, Japanese Red Cross Nagoya First Hospital, 3-35 Michishita-cho, Nakamura-ku, Nagoya 453-8511, Japan. Tel: +81 52 481 5111. Fax: +81 52 482 7733. E-mail: [email protected]
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