Septiceamia and pre term labour due to severe diverticular abscess in pregnancy.

Dear Editor,

A 33 year old primiparous patient presented to our Obstetric triage at 24 + 3 weeks gestation with pyrexia and left iliac fossa pain. Significant medical history included a background of diverticular disease, gastric ulcer and previous cholecystectomy for bile acid malabsorption. Routine investigations on admission revealed elevated inflammatory markers, a swinging pyrexia and positive urine dip. A renal ultrasound reported the presence of renal calculi with no evidence of hydronephrosis. The patient was treated with intravenous antibiotics for a differential diagnosis of pyelonephritis. One day following admission she complained of lower pelvic pains and examination revealed a dilated cervix of 2 cm with bulging membranes. She completed a course of steroids and magnesium sulphate in view of threatened pre term labour for fetal lung maturation and neuroprotection. She rapidly developed septicaemia and proceeded to deliver a live female baby.

Post-delivery she continued to have swinging temperatures despite broad spectrum antibiotics and developed septic shock. An urgent CT pelvic scan reported a possible left tubo- ovarian abscess. She was taken to theatre for an urgent laparoscopy and was noted to have a large diverticular abscess on the sigmoid colon fistulating into the left abdominal wall, involving the left ovary and salpinx. Due to significant inflammation and necrotic tissue she underwent a defunctioning- loop ileostomy and pelvic washout. She continues to make good progress with a future plan for ileostomy reversal surgery.

Diverticular disease in pregnancy is extremely rare. Only one study reviewing a 20 year period of pregnancies within an obstetric department reported an incidence of 1 in 6000 pregnancies [1]. It commonly presents with uncomplicated diverticulitis in which bowel rest and antibiotic therapy are the mainstay treatment. The disease itself is often one associated with an elderly population. A prevalence of 65% has been reported in over 85 year olds compared to 5% among patients less than 40 years old [1]. Recent literature however, reports increasing incidence among younger patients between 18–44 years old presenting with more aggressive forms of the disease [2]. A review of patients by Weizman at al reported a five -fold increase in risk of complications such as fistula formation, peri-diverticular abscess, perforation, strictures and obstruction when compared with older patients [2]. Given the presumption of a low incidence of the disease within younger patients, it is not surprising to find a high percentage (50%) are often misdiagnosed at presentation- most commonly with appendicitis [2].

It has been reported that 30% of cases of pre term labour are secondary to infection [3]. Elevated concentrations of inflammatory cytokines such as Interleukin- 1 and tumour necrosis factor within the amniotic fluid produced by the maternal decidua and fetal membranes, have been found in patients presenting with pre term labour <30 weeks gestation [4]. Such cytokine mediated inflammation is thought to trigger pre term contractions, cervical ripening and rupture of membranes [3]. Therefore any infectious stimuli such as intra- abdominal sepsis in pregnancy, can potentially initiate cytokine release and the onset of pre term labour.

It is important to consider diverticular abscess as a differential diagnosis of swinging pyrexia in pregnancy, as evidently it can be associated with significant maternal and fetal morbidity. In view of recent evidence of an increasing prevalence among a younger population in the Western population, it is certainly a condition Obstetricians may expect to see increase as more women delay their pregnancies till later in life. Early imaging and antibiotics may improve overall maternal and fetal outcomes. If operative intervention is required, the decision for tocolysis or early delivery prior to surgery should be discussed with a multidisciplinary team.

Conflict of interest

None.