Pyometra after ovum retrieval for in vitro fertilization resulting in hysterectomy.

OBJECTIVE: To report infection and pyometra after ovum retrieval for IVF. DESIGN: Case report. SETTING: Community hospital. PATIENT(S): A 43-year-old woman with a recent history of ovum retrieval presented with high fever, chills, and no gynecologic symptoms. The patient was admitted to the medical intensive care unit due to septicemia. After an extensive workup for fever, the patient was diagnosed with pyometra, and biopsy of the endometrial cavity revealed vancomycin-resistant enterococci. INTERVENTION(S): The patient was treated with antibiotics and then discharged home. Two weeks later she presented with unrelenting fever and abdominal pain and underwent hysterectomy. MAIN OUTCOME MEASURE(S): Unrelenting infection despite antibiotic treatment resulting in hysterectomy, which showed autolyzed endometrium, subserosal and intramural abscess. RESULT(S): Infection resolved after hysterectomy. CONCLUSION(S): Pyometra should be considered in the differential diagnosis of fever after ovum retrieval as it may result in serious consequences and can be life threatening.

Three simple steps during closed laparoscopic entry may minimize major injuries.

OBJECTIVES: To describe three steps: (1) the initial Veress pressure (VIP-Pressure), (2) transient high-pressure pneumoperitoneum (HIP-Entry) prior to trocar/cannula insertion, and (3) visual entry with a trocarless cannula during closed laparoscopic entry, which may reduce major injuries. DESIGN: Prospective observational cohort study (Canadian Task Force Classification II-2). SETTING: University-affiliated teaching hospital. INTERVENTIONS: VIP-Pressure. During laparoscopic entry, the initial VIP pressure was measured and correlated against the body habitus and parity of 365 consecutive women. HIP-Entry was performed in 2,498 consecutive cases. In 100 women, the CO(2) volume, heart rate, blood pressure, oxygen saturation, and pulmonary compliance were recorded at pressures of 10, 15, 20, 25, and 30 mmHg. Visual entry with a trocarless blunt cannula was performed in 776 women. The cannula, housing a 0 degrees laparoscope, was rotated clockwise applying minimal downward force. MEASUREMENTS AND RESULTS: VIP-Pressure. Pneumoperitoneum was established after one, two or three Veress needle attempts at the umbilicus in 82.4%, 10.9%, and 4.0% of women, respectively. In seven (2.2%), pneumoperitoneum was established at the left upper quadrant (LUQ) during the fourth attempt, and in two (0.6%) entry was abandoned. Median initial Veress pressure was 4 mmHg (range 2-10 mmHg). The VIP pressure correlated positively with women's weight (r = 0.518, p < 0.001) and body mass index (BMI) (r=0.545, p<0.001), and negatively with parity (r= -0.179, p<0.001). HIP-Entry. The abdomen was insufflated to 25-30 mmHg prior to primary trocar/cannula insertion. There were no changes in cardiovascular parameters between 15 and 30 mmHg. A 21% decrease in pulmonary compliance from 15 to 30 mmHg was of no clinical significance. No injury has been experienced with the visual cannula in 776 cases. CONCLUSIONS: (1) A VIP-Pressure (<10 mmHg) indicates intraperitoneal placement of the Veress needle. (2) The use of transient HIP-Entry does not adversely affect cardiopulmonary function in healthy women. (3) Visual cannula offers an additional step towards safer entry.