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Abdominal Pain and Fever 48 Hours After Hysterosalpingography

Federal Practitioner. 2023 November;40(11)a:389 | doi:10.12788/fp.0428
November 3, 2023|Federal Practitioner
CPT Andrew Evans, MD, USA;ENS Roland Kiendrebeogo, USN;CPT Grace Covelli, MD, USA;CPT Christopher Russo, MD, USAF;MAJ Caitlin Christoffel, MD, USA
Author and Disclosure Information

CPT Andrew Evans, MD, USAa; ENS Roland Kiendrebeogo, USNb; CPT Grace Covelli, MD, USAa; CPT Christopher Russo, MD, USAFa; MAJ Caitlin Christoffel, MD, USAa

Correspondence: Andrew Evans (andrewamcas@gmail.com)

aWalter Reed National Military Medical Center, Bethesda, Maryland

bUniformed Services University of the Health Sciences, Bethesda, Maryland

Author disclosures

The authors report no actual or potential conflicts of interest regarding this article.

Disclaimer

The opinions expressed herein are those of the authors and do not necessarily reflect those of Federal Practitioner, Frontline Medical Communications Inc., the US Government, or any of its agencies. This article may discuss unlabeled or investigational use of certain drugs. Please review the complete prescribing information for specific drugs or drug combinations—including indications, contraindications, warnings, and adverse effects before administering pharmacologic therapy to patients.

Ethics and consent

Consent was obtained from the patient whose information is in this case report.

Complications

TOAs can carry significant morbidity and mortality, and there are both acute and chronic complications associated. Even if properly treated, TOAs can rupture leading to severe illness, such as peritonitis and septic shock. This often requires surgical intervention and hemodynamic pressure support in the intensive care unit setting.16 One of the most feared long-term complications of TOAs is infertility secondary to structural abnormalities of the female reproductive tract.10 Adhesions, strictures, and scarring are associated with TOAs irrespective of medical or surgical management, and thus any women with a history of PID or TOA require advanced fertility workup if they are having difficulties with conception or implantation.17

Minimizing infectious transmission also is essential in the treatment of TOA/PID. All women who receive a diagnosis of PID or TOA should be evaluated for gonorrhea, chlamydia, HIV, and syphilis. Women should be instructed to abstain from sexual intercourse until therapy is complete, symptoms have resolved, and sex partners have been treated for potential chlamydial or gonococcal infections. All contraceptive methods can be continued during treatment.

Conclusions

This case presented several challenges as the bilateral TOAs developed postprocedure in a patient without risk factors. Furthermore, this case did not follow the classic presentation of ascending bacterial translocation to the ovaries over days to weeks. The diagnosis was complicated by a largely benign physical examination and a pelvic examination without evidence of abnormal vaginal discharge or cervicitis. The only indicators were fever, leukocytosis, and abdominal pain in the setting of a recent, uncomplicated HSG procedure. Vigilance is required to obtain the necessary history, and the differential of TOA must be broadened to include women without a history or symptoms of a sexually transmitted infection (contrary to the classic association). We aim to encourage heightened clinical suspicion for TOAs in patients who present with fever, leukocytosis, and abdominal pain after recent HSG or other intrauterine instrumentation procedures and therefore improve patient outcomes.

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