STREPTOCOCCAL TOXIC SHOCK SYNDROME (STSS) AFTER IMMEDIATE POST-PARTUM INTRA-UTERINE DEVICE INSERTION

Toxic shock syndrome from an intrauterine device (IUD) is very rare, but should still be considered as a source of infection in postpartum patients that rapidly deteriorate. Absolute contraindications for immediate postpartum IUD insertion are intrauterine infections at the time of delivery and postpartum hemorrhage. Toxic shock syndrome (STSS) is an acute life-threatening infection caused by Staphylococcus or Streptococcus species. STSS is commonly caused by neglected foreign objects in the vagina such as tampons, but rare cases may occur arising from an intrauterine device.

This is the case of a 16-year-old primigravid with no known risk factors who delivered vaginally at a tertiary hospital in the Philippines. Immediate postpartum IUD was inserted as her contraception of choice. After twelve hours, the patient presented with sudden onset of high-grade fever and refractory hypotension with no associated postpartum hemorrhage. Broad-spectrum antibiotics and inotropes were initiated, and the intrauterine device was removed. Blood and IUD culture studies revealed growth of Streptococcal pyogenes confirming the diagnosis of TSS. Antibiotics were shifted based on the culture sensitivity results with the patient responding well to treatment. She was discharged on the 5th postpartum day with an unremarkable course in the wards.

A review of her history revealed that prior to her admission at our institution, the patient attempted to seek consult at several different hospitals. At each hospital, the patient underwent an internal examination, increasing the risk of developing chorioamnionitis. This was confirmed by histopathologic examination of the placenta with findings of neutrophils in the sub-chorial intervillous space.

The aim of this study is to highlight the importance of maintaining a high index of suspicion for IUD-related infections, prompt antibiotic administration, and removal of the device to eliminate the source of infection.