The strictured segment of small bowel including the perforation was resected. HIF inhibitor A salpingo–oophorectomy and an
appendicectomy were done. A manual end-to-end ileal anastomosis was fashioned and the abdominal cavity thoroughly lavaged with copious amount of saline. No drain was inserted because of the friable nature of the bowel and the localized nature of the peritonitis. Unfortunately, due to financial difficulties, microbiology of the purulent exudate was not requested and the excised specimen was not sent for histological examination. She received a therapeutic course of intravenous ceftriaxone 1 gm tds and metronidazole 500 mg tds for 7 days that covered the aerobes and anaerobes for a week. Apart for an ileus of 3 days, her recovery was uneventful. She was discharged on the 9th postoperative day on a 1 week course of doxycycline against Chlamydia trachomatis a frequent cause of pelvic inflammatory disease. Discussion During surgical abortion, perforation
of the uterus can occur or there may be damage to the cervix, which can predispose to the risk of preterm labour in subsequent pregnancies (cervical incompetence) . There is also an increased risk of injury to infected tissue such as a tubo-ovarian abscess and spreading of the infection [3, 4]. In general, surgical procedures of the female genital tract place the patient at risk for pelvic inflammatory disease, with about 15% of pelvic infections occurring after procedures that break the cervical mucous barrier . The incidence of upper genital https://www.selleckchem.com/products/ly2606368.html tract infection Cyclin-dependent kinase 3 associated with first-trimester abortion is about 1 in 200 cases and the incidence of complications after a first-trimester D&C is 1.7% . Uterine perforation with small bowel involvement is rare in 1st trimester abortion. Shulman et al.  reported a case of uterine perforation and small bowel incarceration two days after a first trimester surgical abortion and correlated the sonographic and surgical findings. Without a preliminary
ultrasound scan it is uncertain in this case if the tubo-ovarian abscess was present at the time of the ‘D’ and ‘C’ or was a complication of the procedure. The clinical course of the combined complications of a tubo-ovarian abscess with small bowel obstruction and small bowel perforation can be explained in four possible patterns: (1) contaminated curettage instruments, (2) pre-existing tubo-ovarian abscess, (3) ‘sealed –off’ tubo-ovarian perforation and (4) unrecognized uterine injury with intra-abdominal involvement [9–12]. The evidence for (2) and (3) is that pelvic inflammatory disease may fix the uterus and moving it with dilators may tear it, spread the pus, and cause a fatal peritonitis . The evidence for (4) is the presence of the ileal perforation within the abscess cavity and, the rarity of the reverse occurring – a tubo-ovarian abscess perforating into small bowel [5, 13].