A rapidly growing adenomyosis associated with preterm delivery and postpartum abscess formation
Taiwanese Journal of Obstetrics & Gynecology
Adenomyosis usually occurs in women of reproductive age, and poor pregnancy outcomes in women with adenomyosis have been reported. The incidence of adenomyosis associated with pregnancy appears to be 17%  . Recent reports showed that pregnant women with adenomyosis are at elevated risks of miscarriage, preterm delivery, preterm premature rupture of membranes, spontaneous uterine rupture during labor, and postpartum hemorrhage  . Here, we report a rare case of a rapidly growing adenomyosis
... growing adenomyosis associated with preterm delivery and postpartum abscess formation within adenomyosis. A 34-year-old nulliparous woman visited our hospital for antenatal care at 6 þ4 weeks (6 weeks and 4 days) of pregnancy. She presented with a previous history of menorrhagia and dysmenorrhea. She had been diagnosed with adenomyosis during a prior pregnancy and previously underwent uterine curettage for septic abortion ( Figure 1A and B). Magnetic resonance imaging (MRI) at 15 þ4 weeks demonstrated diffuse enlargement of the uterus with adenomyosis, which was of homogeneous, low-signal intensity according to T1-weighted images ( Figure 1C ). At 19 weeks, she was admitted due to irregular uterine contractions and a reduced cervical length (1.9 cm). At 22 þ4 weeks and 29 þ2 weeks, cervical length was further reduced to 0.95 cm and 0.2 cm, respectively. At 30 weeks, membrane bulging into the vagina was noted. Cesarean delivery was performed due to breech presentation with powerful contractions and remarkable cervical changes. She had an uneventful postoperative course, and was discharged on Postoperative Day 5. During follow-up visits at 2-weeks and 6-weeks postpartum, uterine enlargement was still evident. At approximately 8 weeks after delivery, she developed a high fever and experienced a profuse, foul, odorous discharge after completing her first menstruation. Computerized tomography depicted an intrauterine, necrotic, degenerated cystic mass of 12 cm in diameter containing air bubbles ( Figure 1D ). The mass resembled one cystic space with multiple septa and papillae within the uterus and was connected to the endometrial cavity. It was presumed to be an abscess within the myometrium. Gram-positive bacteria (nonspore forming bacilli) were cultured from the vaginal discharge. Intravenous antibiotics were administered, and transabdominal catheter drainage was recommended, but she refused the procedure. During subsequent observation following antibiotic administration, she became afebrile. The purulent materials drained spontaneously for approximately 2 weeks, and she was discharged at 10 þ5 weeks after delivery. At 6-months postpartum, pelvic MRI revealed no more evidence of abscess accumulation ( Figure 1E) . Although a few reports have described abscess formation in endometriotic foci, reports on abscess formation arising within adenomyosis are rare. Erguvan et al  reported the first case of abscess in postmenopausal woman (Table 1) [3e5], although the authors did not demonstrate how the abscess formed. Functional changes of adenomyosis during pregnancy and after delivery have also been reported. These cases displayed decidualization and hemorrhage within adenomyosis. In those cases, a relative ischemic condition might develop after childbirth due to rapid decrease in blood flow to an enlarged adenomyosis  . Here, we report for the first time development of an abscess within adenomyosis during postpartum involution. Contributory factors, such as hemorrhage inside the adenomyotic lesions or ischemia after childbirth, might play roles in the development of postpartum abscess. We suggest that the resumption of menstruation might be another factor. Menstruation is considered an inflammatory process , during which intramyometrial menstrual flow and endometrial shedding from the ectopic endometrium within adenomyosis might precipitate abscess formation. In our case, abscess occurred 3 days after completing the first menstruation after delivery.